Vpublic HEALTH REPORTS .V .OL~35 NOVEMBER 12, 1920 No

vPUBLIC HEALTH REPORTS .V .OL~35 NOVEMBER 12, 1920 No. 46

A STUDY OF THE RELATION OF FAMILY INCOME AND OTHER ECONOMIC FACTORS TO PELLAGRA INCIDENCE IN SEVEN COTTON-MILL VILLAGES OF SOUTH CAROLINA IN 1916.1 By JOSEPH GOLDBERGER, Surgeon; G. A. WHzzLER, Passed Assistant Surgeon; and EDGAR SYDEI- STRICKEE, Statistician, United States Public Health Service. CONTENT& I. Review of literature. III. Fellagra incidence according to eco- II. Plan aid methods of present study. nomic status. Locality. Discussion. Population. (a) Bad hygiene and sanita- Pellagra incidence. tion. Season. (b) Difference in age and Dietary data. sex composition. Data relating to economic condi- (c) Differences in diet. tions. Differences in incidence Family income. among households. Availability of food supply. Differences in incidence Economic classification. among villages. Method of classification ac- IV. Discussion. cording to economic status. V. Summary and conclusions. Results of classification. VI. References. In the spring of 1916 we began a study of the relation of various factors to-pellagra incidence in certain representative textile-mill communiities of South Carolina. On a varying scale the study was continued through 1917 and 1918. The results of the first year's (1916) study with respect to diet,2 to age, sex, occupation, disabling sickness,3 and to sanitation4 have already been reported. At the present time we wish to record the results of the part of the study dealing with the relation of conditions of an economic nature to the incidence of the disease. L REVIEW OF LITERATURE. A close association of pellagra with poverty has been repeatedly remarked upon since the time of the first recognition of the disease. In the earliest account, Casal (1870, p. 93), discussing the diet of those 1 From Field Investigations of Pellagra. Submitted for publication Aug. 31,1920. 2 Goldberger, Wheeler, and Sydenstricker, 1918 and 1920a. I Goldberger, Wheeler, and Sydenstricker, 1920b; Sydenstricker, Wheeler, and Goldberger, 1919. 4 Goldberger, Wheeler, and Sydenstricker, 1920c. 15712-201--- (2673) Novemsber 12, 1920. 2674 persons attacked by the disease, remarks that "they eat meat very rarely since most pellagrins are poor field laborers, and this. circum- stance does not permit them -to eat meaat daily nor even from time to time." Continuing, he says: "Their only beverage is water. Their clothes, beds, habitations, etc., are strictly in keeping with their extreme poverty." Further along, discussing the treatment of-the disease, C-asal states that "milk, thanks to the butter it contains, is certainly capable of supplying the nutritive lack of the other foods; they iise it but rarely without having first removed the butter, since these poor people sell the butter in order that they may be able to buy other lnecessaries, thus using in their own diet what remains in the milk after having thus treated it." Much more definite and direct is Strambio (1796) who states that "thus much is certain, that pellagra is most at home where poverty and misery reign and increases as they increase." "Y. VTery interesting and significant is Marzari's observation.5 "I have several times observed," he states, "that if a villager falls into poverty, as happens so often as a result of a storm, droug1-or other calamity, pellagra does not fail to crown his misfortune and piut an end to his miserable existence." Holland (1820), in introducing his discussion of the cause and symptoms of pellaOr in a paper read in 1817, baed on observations of his own and on information secured from Italian physicians in the course of a journey to Italy, remarks: "The pellagra is a malady confined almost excIusively to the lower classes of the people; and chiefly to the peasants and those occupied in the Iabors of agriculture." He repeats this two or three times in other connections. In his discussion of the etiology of the disease (p. 322) we find the following highly suggestive statements: "Though I have spoken of Lombardy as one of the most fertile portions of Europe, yet to those who consider the little certain relation between mere productiveness of soil and the prosperity or comforts of the population dwelling upon it, it will not appear very extraordinary that the peasants of this diss- trict should be subject to various physical privations unknown to the people of countries which are much less favored by nature. The fact unquestionably is, whatever be our speculations as to the cause, that the peasants of Lombardy do for the most part live in much wretchednless, both as regards the quantity and quality of their diet and the other various comforts of life. It further seems probable, if not certairn, that this evil has been progressively augmenting within the last 5 years; partly, perhaps, an effect of the wars which have so often devastated the country by marches and military contribu. tions; partly a consequence of the frequent changes of political state; together with the insecurity, the variable system of government, and 6 Cited by Russen, 1845, p. 167. 2675 Novesber 12,1l920.. the heavy taxes and imposts attending such changes. To these causes may be added a decaying-state of commerce and a faulty system of arrangement between landlords and the cultivators of the soil, all tending to depress agriculture and to reduce the peasanfy at large to a state of much misery and privation." Coxiing this discussion, Holland remarks further (p. 333): "Animal food rarely forms a part of their diet, and although living on a soil which produces wine their poverty almost precludes the use of it, even when sickness and debility render it most needful. The same condition of poverty is evident in their clothing, in their habitations, and in the want of all the nor necessaries and comforts of life. The imniediate effect of these privations is obvious in the aspect of squalid wretchedness and emaciation which. forms so striking a spectacle at the present time throughout the greater part of Lombardy. I say particularly at the present time," because whatever may have been the progress of misery among the peasants of this country during the last half cen- tury it appears to have increased in a tenfold ratio during the last two years, the effect of bad harvests added to the preceding wars and political changes which have distressed this part of Italy." Hameau (1829), in the first recorded observations of pellagra-in France, reported that "this disease attacks individuals of both sexes and all ages, but I have not yet seen it in any but the poor and un- cleanly who subsist on coarse food." Lalesque (1846), in his account of pellagra of the Landes, cites a number of instances illustrating the conditions of misery under which pellagra occurred, finally oxclaiming (p. 421): "These are, the individuals attacked by pellagra, for it attaches itself to poverty as the shadow to the body." In a discussion of pellagra in Gorz-Gradisca, Berger (1890) very significantly observes: "The appearance during the last decennium of diseases-of the vine, the reduction in value of the product of the soil because of foreign competition, crop failures, increase in taxes, increasing living costs, all operated to undermine economic conditions, particularly of the poorer country folk, and thus prepared favorable conditions for the spread of the disease." Discussing the therapy and prophylaxis of pellagra in Bessarabia, V. Rosen (1894) bewails the attendant difficulties "in that, on the one hand, the alimentation with commeal porridge is a deeply rooted national custom, and, on the other, that the disease attacks the.poorest class of the population; 'N'am vaca, n'am lapte a casa' ('I have no cow and no milk in the house') is uniformly the reply of the patient to questions in relation to this subject," and Sofer (1909, p. 219), discussing the economic status of pellagrins (in Austria), remarks that "89.9 per cent haven't even a cow." Italics in o'rigal 26764 The xtremely unfavorable economic conditions of those subject to pellagrm (in Austria-Hungary, at least), is further strikingly suggested by the chaeacter of sowe of the recommendations for its con troL Thus Von Probizer (1899, p. 141) urged, as a necessar nmas- ure, "pecunry aid by the Government in view of the deplorable condition of the peasantry in the affected localities." V. Babes (1903), writing on pellagra in Roumania, remarks (p. 1187) taat "practically all pelagrins are very poor;" and goes into some detail in describing the unfavorable economic condition of the Roumanan peasant, which leaves him in debt to the landowner and the tax collector. In modern Spain we have Caarza (1870) remarlking (p. 66) that although he had seen cases in well-to-do individuals, the disease only exceptionally occurred mi those of this claw. He adds (ph 67) also that in his experience, unike the reported observations Qf others (Roussel, 1866, p. 431), pellagra is quite common in beggas. ' In discussing the etiological rdle of widowhood, this keen observer expresses the opinion (p. 68) that this plays a part only in proportion as it tends to bring about a depression in economic well being and a consequent insufficient alimentation. Huertas (1903) describes the disease as occUring amon the most miserable class of the population of Madrid, who live on the food picked from the city's garbage. In Egypt Sandwith (1903) found the disease highly prevalent among the poorer peasants of Lower Egypt. "In one viUage," he reports, "where the inhabitants are especially well to do because they get regular pay throughout the year from the Domains administra- tion, there were only 15 per cent of pellagrous men, while among the men of the village, which has the reputation of being the poorest, the percentage rose as high as 62." Gaumer (1910), discussing pellagra in Yucatan, states that the disease did not become epidemic in that State until 1884, two years after a destructive invasion by locusts or grasshoppers. "Among the better classes the disease seldom made its appearance. * * * It was the middle and lower classes who, from reduced circumstances, were obliged to purchase the cheapest corn in the market that suffered most from the ravages of the disease." "Fron 1891 to 1901 Yucatan produced sufficient corn for home consumption, and new cases of pellagra were no longer to be found, * * *"t "From 1901 to 1907 the corn crops wero almost total failures and corn was again imported in greater quantities than ever be.' fore * * *. "Pellagra again became epidemic, but was not then confined to the middle and lower classes, as in the former invasion. The wealthy hemp owners, on account of the exorbitant prices paid for hemp, 2677 Wouember 12, 1020. found it was more profitable to import than to raise corn for home consumption, thus compelling even well-to-dofpeople to.consume the imported article," which was believed to have been spoiled in transportfrom the United States. "Pellagrsthen spread alike among the rich and poor, until by the close of 1907 about 10 per cent of the inhabitants were victims of the disease * * *' In Barbadoes, B. W. I., the disease, according to Manning (1907), is "confined to the laboring classes and is most prevalent among those who are badly off or poverty stricken. It is very seldom found among the whites, but cases do occur among those in straightened circumstances." In the pioneer reports 6n pellagra in the United States such references as are made to the relation of economic status to the disease are of a very general character and appear for the most part to be echoes of European opinion. ' So far as we are aware credit for the first study of this relationship is due to Siler and Garri- son (1913). This study was made in South Carolina in 1912 and relates to pellagrins alone. In recording their data relating to the economie conditions under which the patients lived, Siler and Garrison adopted five classes, namely, squalor, poverty, necessities, comfort,-and affluence. Of the 277 cases so classified, the economic conditions were reported as poor (squalor, poverty, necessities) in 83 per cent, within the average (comfort) in 15 per cent, and well above the average (affluence) in 2 per cent. Jobling and Petersen (1917) in their second year's study of the epidemiology of pellagra in Nashville, Tenn., "endeavored to make a most accurate study of the economic condition of pellagrous patients." "In order to do this," they stato that their examiners "ascertained the average rentals for the entire city, the weekly income of the pellagrin when a wage earner, and the total income of the pellagrous family." From these data the amount of money available for each pellagrin per week was computed by dividing the total-income by the number of individuals, children being accorded the same value as adults. They found that 70 per cent of their white adult male pellagrins were wage carners, more than 60 per-cent of whom earned $10 or more per week. Of the white adult females, 22 per cent were wage earners, and of these, 56 per cent earned less than $10 per week. Of the colored wage earners, 66 per cent of the' males eamed less than $10 per week, while a similar per cent of the females earned under $8 per week. When the amount of money available for each pellagrin per week was estimated, Jobling and Petersen found that of the whites 56.5 per cent and of the colored 94 per cent had an available income of $2.50 or more per week. November 12, 1920. 21678 lThese workers also made an estimate of the economic status of the pellagrous clas on the basis of rentals, which they considered a "fairly reliable basis" for this purpose. They found that of the whites 11 per-cent and gf the colored 16 per cent owned their own homes or were buying them on the installment plan. "The rentals paid by the balance were practically all under $15 per month, only 3 per cent of the cases occurring in families paying more than this amount. Of the colored families few pay more than $8 per month." It will be observed that the study of Jobling and Petersen, like that of Siler and Garrison, concers itself exclusively with the pellagrin. Neither study affords any bass for a comparison with the economic distribution of the general population so that neither these nor, so far as we are aware, ally previous observations give us any means of measuring in a definite objective manner the degree of association between economic status and pellagra incidence. This &ficiency we have endeavored to repair by the study that we shall now-proceed to detail. II. PLAN AN) METHODS OF PRESET STUDtr. LOCALITY. The studv was made in seven representative cotton-mill villages situated in the northwestern part of South Carolina. POPULATION. The villages were of about average size; none had over 800 or less than 500 inhabitants. Each constituted a distinct, more or less isolated community in close proximity to a cotton-cloth manufacturing plant and was composed practically exclusively of the mill employees and their families. The few Negro families present and living somewhat apart were not considered, so that our study deals with an exclusively white population, which, with hardly a single exception, was of Anglo-Saxon stock born in this country of American-born parents. Besides the, Negroes, there, were also excluded from this study the mill executives, store managers, clerks, and their households, so that we had left for study an exceptionally homogeneous group with respect to racial stock, occupation, and general standard of living, including dietary custom. An enumeration of the population was nrade in May and June in connection with the collection of our dietary and economic data, and totaled about 4,160 people, included in about 750 households. PELJ.AGRA INCIDENCE. The protedure adopted for determining the incidence of pellagra in this population has been described at length in a previous paper of this series.7 I Goldberger, Wheeler, and Sydenstricker, 1920 a. 26-79 November 12, lWO Briefly, in order to ascertain the incidence of the disease as com- pletely- as possible, the expedient of a systematic biweekly houseto- house search for cases was employed and practically exclusively depended on. Only cases with a clearly defined, bilaterilly symmetrical dermo- titis were recorded as pellagra; cases with poorly defined eruptions, or those with more or less suggestive manifestations but without clearly marked eruption, were recorded at most as "suspects" and are excluded from present consideration. Just as in our study of pellagra incidence in relation to diet, so here, in relating pellagra incidence to economic conditions, no distinction is made between first and recurrent attacks, but all active cases as above defined are considered. So-called inactive or quiescent cases, that is, individuals who had had the disease in a previous year but during t916 presented no definite eruption or evide4ce sufficient to be classed as "suspects," are considered as nonpellagrous. As a considerable proportion of the population of any village is of transient character,8 and as much of the pbllagra occurs in this class,9 some assumption was necessary on the basis of which cases might be assigned to households and villages. Accordingly the rule was adopted that a case was to be charged to a household or village only if the affected individual had been a member of that household or had resided in the village not less than 30 days immediately preceding the beginninig-of the attack (as above defined). SEASON. It would seem reasonable to expect, if diet, economic status, or other factor has any influence in relation to the seasonal rise in incidence of the disease, that this influence is most effective during a eSee in this connection Goldberger Wheeler, and Sydenstricker, 1920 b. 'This is lelarly suggested by the folowing table, length of residence being assumed to be a fir inder of the moving habit of the holsehnd. Pellnam incielence in famUies, according to length of resi"ence, in seven cotton-mil. villages of South Caolina 4euring 1916.

Families classified Pellagra incidence according to in families re. length of resi- siding spcifod dence in village. pe in village. Length of residence in village. - Numiber Pe cent Number Percent |eon- residing of pelIa- of famies ~~~~~~~~~~~~~~~~~~siee. spIfedpl

&ny,period ...... 753 |10.0 7.4 56 Less than I year ...... 297 3239.510. 8 Iye.74 9.8 5 6. 8 2-4years ...... i...... 189 9 4.8 . 1 4yesormore...... 93 25.610 5.2 'ovember 12, 120. 2680 period immediately anterior to the sharp rise and peak of incidence. Such statistics of pellagra morbidity as were available to us at the beginning of our study indicated that the rise of the seasonal curve of pellagra incidence in the southern States began in the late spring and reached its peak in June. It was assumed, therefore, that the factors favoring the production of pellagra were most effective during the season beginning some time in the late winter or early spring and continuing up to or possibly somewhat into June. The period actually selected by us as representative of this season extended from April 16 to June 15, 1916. Information relating to family income, household food supply, and the composition of the households, etc., for sample sections of this period was secured by trained enumerators who canvassed the village in successive 15-day periods under the immediate direction and supervision of one of us (E. S.)

DIETARY DATA. The methods adopted for securing data relating to diet have been described fully in a previous communication (Goldberger, Wheeler, and Sydenstricker, 1920 a). It-will suffice in the present connnection to recall that these data relate to the food supply of the household, not to that of the individual, and so do not indicate the differences that may have existed in the diets of the individual members. It being impracticable to secure our dietary data simultaneously in all villages, the record of household food supply secured in the several villages was for successive 15-day periods between April 16 and June 15. It was assumed that an accurate record for a 15-day period would be a sufficiently representative sample of the supply of the season inumediately anterior to the peak of seasonal incidence of the dicase, that is, of what may be considered as the pellagra-producing season. DATA RELATIN-G TO ECONOMIC CONDITIONS. Since nearly 90 per cent of the individuals composing the popula-_ tion studied were found to be dependent upon the income of family groups composed of more than one person, family income was adopted as the basis for classifying the population according to economic status. Family income.-The data relating to family income were secured by inquiries of the housewife or of some other responsible member or members of each family, supplemented by data from the, mill pay rolls. For the latter we are greatly indebted to the willing cooperation of the administrative officials of the mills. The information obtained from the families covered (a) the rate of daily earnings of eachi member earning wages during the half 268I November 12, 1S20. month preceding the week of the canvass and the various rates of daily earnings of all members who had been employed during tbe 12 preceding months; (b) the days not at work for all members who had worked for wages during the 12 preceding months; (c) the income from all other sources during the preceding half month as well as during the preceding 12 months, this information being secured in detail for each source of income. On the basis of this information it was possible to approximate the total income of each family for the half month preceding the visit of the enumerator, and, roughly, for any part or all of the preceding year. Finding that approximately 90 per cent of the total income of the families studied came from the earnings of wage-earning members, the family statements of earnings during this half-month period were compared with the records on the mill pay rolls, and, in the great majority of instances, were found to agree closely with them; but in order to reduce the error arising from even slightly inaccurate statements as to wages, the pay-roll records instead of the family statements have been used to supply the earnings data. For that small proportion of family income made up of wages earned in employment outside of the mills and of the amounts derived from other miscel- laneous sources, the family statement was necessarily accepted. On the basis of the results of some prelimninary tabulations it was decided that the family income during the half month preceding the week of the enumerator's canvass would be a fairly accurate indi- cation of family income during the season selected as most significant in relation to the occurrence of pellagra. The basis for classifying families with respect to income was, therefore, the total cash income of each during a 15-day period between April 16 and June 15, 1916. A half-month sample period was used, partly because it corresponded to the sample period for which dietary data were secured and partly because a majority of the mills in the villages paid at semimonthly intervals. The pay-roll data from other mills were adjusted to a half- month basis. In the course of the canvass of the homes of the mill workers' families other data affecting the economic status of the families were also collected. These related principally to length of experience in mill work, occupational status of wage earners, and the amount and incidence of disabling sickness 10 among wage-earning and other members of households. Availability offood supply.-With the view of studying the relation of food availability to pellagra incidence, information was collected under the imnmediate direction of one of us (E. S.), relating to conditions that might effect the supply of a given food or foods. In collecting and recording this information a uniformn method was 10 See Sydenstricker, Wlheeler, and Goldberger, 1918. November 12, 1920. 2682 followed as closely as possible except where specific points suggested the advisability of special inquiry. The principal sources ofinfor- mation and the nature of the information sought were as follows: (1) Statements were obtained from households as to the immediate source of every article of food entering into their hall-month's supplies. Thus it was ascertained, for example, whether the fresh milk used by the household was produced at home, purchased from another mill worker's household in the village, or from some specific farmer, dairy, or store, or donated by a relative, neighbor, or other person. In the event that a household had a source of supply not common generally to households in the village, inquiries were directed with a view of ascertaining the length of time the household had had such a supply, particularly, with respect to the period after January 1, 1916. (2) From farmers, hucksters, or "peddlers" selling fron,vhouse to house, statements were secured relating to the quantities sold, prices, frequency of selling, and character of produce sold since January 1, 1916. (3) From managers and clerks in the stores, markets, and other xetail establishments at which mill workers' households largely dealt, data were secured relating to (a) priccs during the 15-day period and price changes during 1916; (b) sources of each food sold, whether direct from near-by farms or through middlemen from local agricultural territory or from other sections of the United States; (e) names of brands and quantities of the foods sold; (d) practices with respect to credit to mill workers' households, especially as affected by the- amount of earnings by the mill workers. ECONOMIC CLASSIFICATION. MeAhod of classification according to economic status.-As has already been mentioned, the great majority of the individuals composing the population studied were members of families who sub- sisted on the income of families composed of several persons; the small proportion not subsisting on such family income were boarders living under substantially the same- conditions as the families with which they boarded. It would seem permissible, therefore, to classify these econoically with the members of the family with whith they boarded, although it is fully recognized that in so doing a certain, though, for the present purpose, unimportant, error is involved. In classifying this population according to economic status on the basis of family income the conventional method of using total family income for a given period was found to be so inaccurate in many instances as to be misleading. The average total annual cah income of all of the fmiilies for which income data were secured was 2683 Norember 12, 192&. about $700, and relatively few had annual-incomes of over $1,000. Thus the range of total income was relatively small and the faies were, from this point of view, fairly homogeneous. They diffeted, however, very markedly in size and with respect to the age and sex of their members. Manifestly it was improper to classify, for example, a family whose half-month'simcome was $40, and was eomposed of only a man and his wife, with one whose half-month's income was also $40, but was composed of a man, his wife, and several dependent children. Since family imcome, for the purpose of this study, was used as an index of the economic status of individuals who composed the family group, it was necessary to take imto consideration the number of such individuals in comparing one family with another. A per capita statement of income, however, while more ccurate than the statement of total income, was subject to the inaccuracy arisig from differences in the age and sex of members oi the families td be compared. It appeared advisable, therefore, to employ a commnon denominator to which the individuals of both sexes and of all ages could be reduced in order to obtain a more accurately representative method of expressing the relative size of the families to be compared. In the absence of a better common denominator for this purpose, the Atwater (l915) scale of food requirements was employed, and the size of each family was computed according to this scale and e.x- pressed in terms of "adult male units.""1 The asumption in the use of this scale was that the expenditures for- total maintenance for individuals varied according to sex and age in the same proportion as did their food requirements. The assumption is by no meam as accurate as could be desired; in its favor, however, it may be said that since family expenditures in the great majority of cases equaled total family income, and since food expenditures were nearly half (among poorer families considerably more than half) of total expenditures, a scale based on food requirements alone is obviously very much more accurate than one omitting any consideration whatsoever of the number, sex, and age of the individuals composing the families

lt The scale used was as follows:

Equivalent adult male unit. Agge. Male. Female.

Adult (over 16) ...... t0 0.8 15to 16 ...... 8 .8 13to14 ...... 8 .7 ...... 7 .6 lOtotl ...... 6 .6 6to9 ...... 5 .5 2to5 ...... 4 .4 Under2...... 3...... 3 1'ovember 12, 1920. 2684 to be compared with respect to income.12 For the present purpose, therefore, the total income of each family as defined above, has been divided by the number of " adult male units" subsisting on the family income, and the resulting figure has been termed the "family income per adult male unit." Restdt8 o] ckanjcation.-The 747 families for which income data were sufficiently accurate and complete for consideration have been classified by this method and grouped'into four convenient classea, each containing a fair proportion of 'the total number.- Table I pre- sents-this classification and also the resulting distribution of individuals and their equivalent "adult male units." The differences im income axe also indicated in Table II, which permits of a comparison of the results of classification on the basis of the average income during the half-month period per family, per person, and per " adult male unit." Table III,' based on Table II, permits of the same comparison and perhaps expresses these differences more clearly. It will be noted that the same general differences IIn ordertoestablisha more aurate bis for computingthesize ofhmiliesin comparing their incomes, a detailed study of expenditures forin6dividuals in a number ofrepresentative families In cotton-mill viSl lageswas undertaken during 1917. Whiletbetabulationsofthesedatawerenot completedlntimeforuse In the study of the data collected in 1916, it appears tbt the Atwater scale is roughly indicative of the varla izs,asoccrdingto sex and age,inthe consumption ofallarticles forwhichthere areindividualexpend- ltur. It should be noted that befare using the Atwater scale in tbe preliminary computations of famiy Income, several published e3timates ofthe cost of maintenance for Individualsof various ages were exam- ined. The:eestlmateswere based, in several instances,uponthe results ofinvestigation ofactual expend- ituresofindiviual members of families. Using theestimated expenditures for an adult maleas 100, the estimates f.r Individuals of other ages ofeither sex were expressed relatively and compared with the At- water scale. It appeared that, in most instances, the scales were fairly similr. The foilowing table, computed from probably the most pertinent data available, indicates the relative cost of maintenance (at a "fair standard ofliving") for a year of individuals of various ages as estimated for Southern cotton- mill*orkers by the United States Bureau of Labor in 1911, in compason with the Atwater scale for food requirements. Compariwon of th relative variations in individual expensesfor all purposes with variations in indiridualfood- requirenents according to age and sex.

Male. Female.

Individ- Individ- ual ex- Food re- ual ex- Food re- Age. penses quire- penses quire- (U. S. ments (U. S. ments Bureau (At- Bureau (At- of - water). of water). Labor). Labor).

Adult (over 16) 100 100 89 80 15to16-...... - 79 S 13 to 14 72 80 67 70 12 - 61 70 57 60 l0-to 1 1 56 60 6059 6 to 9-,45 50 46 50 2to 5- - 40 35 40 Under 2 26 30 26 30

Thelnlivdualexpenses estimated were for food (estimated by the U. S. Bureau of Labor, accordilngto the Atwater scale), clothing, medical attendance, and medicines, Insurance, amusements, tobacco, and school.bcoks. See report on Conditions of Women and Child Wage Earners In the United States, VoL XVI, Family Budgets of TypicarCotton-Mill Workers by Wood F. Worcester and Daisy Worthington Woreater, Sen. Doe. 645,61 Cong., 2d sess., 1911, p. 150. 26X, Novembr 12 1920O in average incomes for the four groups are indicated by any of the three methods of classification. For reasons already stated, however, the "adult male unit" method is believed to be more accurately representative of actual conditions than either of the others and, therefore, to be preferred for the classification of individual famnilies; it is the method hereinafter employed. TABLE I. -Number offamilies and members offamilies and thei'r equivalent in adult male units in seven cotton-mill villages ofSouth Carolina, claifted according tofamily income during a 15-day period between Apr. 15 and June 16, 1916.

Half-month family income per adult male unit. Families. Persons.a adult male Ulits.b

Number. Number. Number. Less than $6.00 ...... 217 1,280 86 2 $6. 047.99...... 183 972 675.9 48.09.9.....139 ...... 1 704 529.2 S10.00 ando ...... 268 am 607.1 All ineomes ...... 747 3,765 2,678.2 Per cent. Per cent. Per cent. Allineomes. . -...... 100.0 100.0 100.0 Ls tban 6.00.29.1 3L2 32.4 86.0047.99 . 24.5 25.8 25.2 18. 6 18.7 1.8 $10..00-.99..00andover .27.9 21.3 22.6 a Exclusive of persons paving bo3rd and including only those dependent upon family ineome. b According to the Atwater scale for food requirements. TABLE II.-Average half-month family income, computed in terms of "per familg," "per person," and "per adult male unit," various income classes ofthe populataon in seven cotton-mill villages in South Carolina.afor Average Income during a half All family month. Half-month family income per adult male unit. income halfmonth. Per Per adult family. person.b unit.a

L,ssthan8.60...... 3,990.45 818.38 83.09 84.61 $6.00-87.99 ...... 4,780. S5 _ 26.12 4.92 7.07 S8.00-9.99 . .4, 42.29 33.40 6.55 R 77 S10.00 and over ...... : 7,777.99 37.39 9.72 12.81 All incomes ...... 21,191.58 28.36 5.63 7.92 a According to the Atwater scale for food reqjuirements. b Exclusive of persons paying board and including only those dependent upon family income. TABLE III.-Ratio of the average incomefor each income class to that of all income clases of the population ofseven cotton-mill villages ofSouth Carolina. jThe average income is computed in terms of "per family," "per person," and "per adult male unit."j Relative are ineon during a halfmonth per- Family income per adult male unit. Family. Person. Aduilt maleunit. All incomes.100 100 100 Under 6. 00. 65 55 58 6 .0 0 4 7 .9 9 ...... 92 87 89 ...... 118 116 112 810. 00 and over .132 173 162 November 12, 1920. 2686 Before entering upon a consideration of the relation of family income to pellagra incidence it will be.desirable to make; brief reference to the factors affecting family income. An analysis of our data with a view of determining, so far as practicable, what these were, showed the principalonnes to be as follows: (a>-Supplemental income, chiefly from boarders; (b) the number of dependent persons, principally children, in proportion to the number of wage-eaming persons in the family; and (c) the carning capacity of the wage earners, including chiefly the factors of natural ability, length of training, and state of health. In the classification of this population according to "family income per adult male unit," those persons in the higher income classes appeared distinctly to have the advantage in each of these respects over those in the lower income classes. IL PELLAGRA INCIDENCE, ACCORDING TO ECONOMIC STATUS. Having considered the methods employed for securing the basic data relating to the occurrence of the disease and for securing those relating to the classification of the population with respect to economic status, we may now proceed -to determine the relationship existing between the economic status of the family and the degree of incidence of the disease. We have in all 747 households for which our data are sufficiently complete and accurate to permit of classification according to income. There were recorded among the members of these households 97 definite cases of pellagra. In Table IV we have distributed these households in accordance with the family income per adult male unit during the sample half-month period and have indicated therein also the number and per cent of the households in each of the resulting five income classes that were affected with pellagra to the extent of (a) one or more cases, (b) tw-o or more cases, and (c), three or more cases. It will be observed that the proportion of families affected with pellagra declines with a marked degree of regularity as income increases. This inverse correlation is even more clearly shown when weight is given to households with more than one case of the disease,13 as is done in Table V, in which the incidence of pellagra is expressed as a rate per 1,000 persons in ech income class. ' Upon the basis of the average half-month income per adult male unit for each of the income classes and the corresponding pellagra rate per 1,000 persons, the Pearsonian coefficient of correlation is -0.91:0.05. While the small number of classes considered must, of course, be taken into account, the expression indicates high degree ofcorrelation (-1.0 being perfect inverse correlation). 2687 November 12, 1920. TABLE IV.-Number and per cent of households of dijerent income classes afected with pellagra in seven cotton-mill villages ofSouth Carolina in 1916.

Pellagrous households in which were- All Half-month family income per adult male unit. house- One or Two ore Three or holds. more more Imore- cases of cases of cases of pellagra. pellagra. pellagra.

NUMBER.

Less than $6.00...... 217 28 17 7 $6.00-7.99.. 183 21 3 1 S8.00-59.99 ...... 139 8 4 0 $10.00-513.99 ...... 144 3 0 0 S14.00 andover ...... 64 1 0 0 All incomes .747 61 24 8

PER CENT.

Le$s than $600 .100.0 12.9 7.8 3.2 $6.00-7.99.100.0 11.5 1.6 .5 58.00-59.99 ..... 100.0 5.8 2.9 0.0 510.00-13.99.100.0 2.1 0.0 0.0 $14.00 and over .100.0 1.5 0.0 0.0 Allincomes .100.0 8.2 3.2 1.1

TABLE V.-Number of definite cases of peltagra and rate per 1,0001 among persons of diferent income classes in seven cotton-mill villages of South Carolina in 1916.

Total. 'Males. Females. Half-month family income per adult male Number Rate I unit. Number Number Number Rate Number Number Rate of Per- o ca ps. r of per- ofcss per of per- ofcss per nit ope-sons. ocae.1,000.pe sons. ocae.1,000.ume . sons.be of 1,000.o

Less than $6.00...... 1,312 56 42.7 650 20 30.8 662 36 54.4 56.0047.99 ...... 1,037 27 26.0 521 6 11.5 516 21 40.7 58.00-59.99 ...... 784 10 12.8 376 4 10.7 408 6 14.7 510.00-413.99 ...... 736 3 4. 1 363 0 0.0 373 3 8.0 $14.00 and over ...... 291 1 3.4 161 1 6.2 130 0 0.0

All incomes ...... 4,160 97 23.3 2,071 31 14.9 2,089 66 31.6

1 Since a marked variation in the pellagra rate according to and sex was found for the population studied (Goldberger, Wheeler, and Sydenstricker, 1920 b), ancd agesince, ordinarily, differences in the bution of persons arding to age occur in different economic groups, computation of rates adjusteddi§trL-to a standard population was uade. The influence of differences in the sex distribution in any age group was insi nifieant, and practically the same incidence rates were obtained after making adjustments to a standard age distribution, as is shown in the following table: TABLE Va.- Comparison of crude pellagra rates and of rates after adjustment for age to a standard population for each income class. [Standard population= total popuilation, all incomes.) Case rate per 1,000. Family income per adult male unit. Crude.' Adjusted.

Less than $6.00 ...... 42.7 41.0 00-7.99 ...... 26.0 24.8 51.00-59.99...... OS .>1813.99l ...... 4.1 12.8 14.2 S14.00 and over ...... _. 3.425 56.2 November 12, 1920. '688 The occurrence of multiple-case families, especially from the point of view of difference in income, invites special comment.- The 97 cases of pellagra occurred in 61 fapiilies. In each of 24 of these families, two or more cases occurred, while in each of 8, 'three or more cases developed. Taking into consideration the size of the families and assuming that: all individuals were equally susceptible to the disease,14 a computation of the probability of the occurrence of multiple-case families according to purely chance distribution imdicated that in the 747 families we should expect about 90 families with one case each, about 8 families with two or more cases, while the proba. bility of households each with three or-more cases would be less than 2 in 10,000. The actual occurrence of 24 families with two cases each and of 8 families with three or more cases would thus seem to be far in excess of the result of chance.." The fact that multiple-case families occurred only in the lower-income classes and that families with three or more cases occurred practically only in the lowest- income class plainly shows that the tendency toward concentration of cases in certain families increases as income diminishes. Pellagra incidence in the population studied therefore not only varied inversely according to family income, but with decreasing income it seemed to show an increasing tendency to affect members of the same family. DISCUSSION. The very marked inverse correlation between low income and pellagra incidence naturally calls for explanation. Under the conditions of the study the following possibilities in this regard suggested themselves for consideration: (a) Bad hygiene and sanitation; (b) Difference in sex and age composition of the population in the several income classes; and (c) Difference in diet. (a) Bad hygiene and sanitktion are in general closely associated with poverty so that the incidence of a disease, the dissemination of which is favored by such conditions, may be expected to be unusually high in the lower economic strata. Consequently it is natural to suspect ttat a disease found to be highly prevalent in an environment of poverty is dependent on the almost inevitably attendant unhy- genic and insanitary conditions for its propagation, and to assume that it is of microbial origin. The possibility of an essential infective etiological factor in this disease has therefore been given careful consideration, and in a previous paper (Goldberger, Wheeler, and Syden- stricker, 1920 c) We reported the results of our study of the relation 14 So far as sex and age are concerned, all families (with but few exceptions)contained airlycomparable proportions of "susceptible" individuals. ilAcknowledgment is made to Associate Statistician I. M. PhilUps, United Sta Public Health Service. for assistance in this computation. 2689 ' November 12. 1920. of certain factors of a sanitary character to the incidenceof pellagra in these villages. No consistent correlation was found.lB This, coupled with the results of the other of our own studies (see discussion by Goldberger and Wheelerr 1920, pp.-36-41) and of the studies of other investigators (White, 1919; and Boyd and Lelean, 1919), and with the fact of the complete absence of any unequivocal evidence in support of---an essential infective etiological factor in'his disease, not only renders discussion of hygienic and sanitary factors in the present connection unnecessary but, we believe, permits of their dismissal from further serious consideration. (b) Differences in sex and age composition of tAe population in the several income classes.-We have shown in a previous communication (Goldberger, Wheeler, and Sydenstricker, 1920 b) that the incidence of the disease in the population of these villages differs markedly in the sexes and at certain age periods; it is conceivable, therefore, that differences in the-sex and the age distribution in the different income classes might give rise to the phenomenon under discussion. That this is not the case, however, is evident (1) when it is recalled that we are dealing with a population composed of family units and (2) when wre compare the indications afforded by-Tables V and VI, showing, respectively, the sex and the age distribution of the population of each economic class, and note the agreement.in the indications afforded by the crude rates and by the rates after adjustment to a standard population (footnote to-Table V). TABLE VLI.-Number and per cent of persom in each income class, clam:ified according to age, in 7 coUon-mill-iilages of South Carolina in-1916. (The classes be:ng divided frorm each other at thoseages at which the pelagra incidence rate for the whole population varies most sharply.al Age group. Half-monthi family income per adult male unit. All Under ages. aners NUMBER. Less than 26.00.. 1,312 260 251 317 162 217 49 26.0047.99...... -...... 1,037 162 166 270 172 166 41 60 8.0049999.. 784 104 108 229 149 114 48 32 $10.00413.99. .736 95 69 173 215 102 46 36 $14.00 and over ..291 7 1 71 91 63 9 15 All incomes.4,16) | 60 1,060 789 662 212

PER CENT.

Lss than G00.. . 100 19. 8 19.1 24.2 12.4 16 5 3.7 56.0)D7.99.. 100 15.7 16.0 26.0 16.6 16.0 &58 3.9 8.00-9.99 . 100 13.3 13.8 29.2 19.0 14.5 6.1 _4.4IL 210.00S1399... 100 12.9 9.4 23.5 29.2 13.9 6.2 4.9 114.00 and over.f 100 9.3 5.2 24.4 31.3 21.6 3.1 5.2 All in?omes .100 1x8 14.6 25.5 19.0 15.9 5.1 L * The data collected during 1916 were not in a form to permit the study of the relation of crowding in the home to pellagra inicidenlce. We may state, however, that a preliminary analysis of a considerble mass of data boaring on this collected during 1917, shows verylittle, ifaay, correlationbetweeathem when the effect of income is minimized.poillt, a S GoIdberger, Wheeler, and Sydenstricker, 19 b. 15712°--20O2 November 12, 1920. fflO 1 (c) Differenes in did.-The results of budgetary investigations have repeatedly demonstrated the asociation of marked variations in diet with variation in family income.1' It seemed doubly pertinent, therefore, to inquire what, if any, variations in diet were asso- clated with variations in income among the families of our cotton- mill villages. Accordingly, we prepared Table VII, showing- the average food supply of the households of the several income classes. To facilitate comparison between the averages thus presented, in- dices have' been computed, the figures for the households with the highest income being used as the base. It will be noted that, from the point of view of income, the folowinggeneral tendencies are suggested: 1. The smaller the income the smaller were the supplies purchased of all meats (except salt pork), green vegetables, fresh fruits, eggs, butter, ehese, preserved milk, lard, sugar (including sirup), and canned foods. 2. The smaller the income the larger were the supplies purchased of salt pork and corn meal. 3. In the households of the various income classes the quantities of-the purchased supplies18 of dried peas and beans, potatoes, dried fruits, wieat flour and bread, fresh milk, and rice appeared without any consistent trend. Thus it appears that there were associated with differences in iamily income quite definite differences in household food supplies. In order to determine the outstanding differences more clearly, tho households with intermediate incomes were disregarded and comparison was -made of the food supplies in households presenting the greatest contrast from an economic standpoint (i. e., those households representing the respective extremes of family income), with the---result that not only did the differences already noted stand out more clearly, but, in addition, it appeared that the supplies of wheat flour and bread and of fresh milk were appreciably smaller in the poorest households. -In that part of our study dealing with the relation of household food supply to pellagra incidence (Goldberger, Wheeler, and Syden- stricker, 1920a) a very definite significant relationship between the character of the diet and the incidence of the disease was demonstrated, and since, as we have seen above, a marked inverse correlation exists between the amount of family income and the degree of mcidence of the disease, it follows that the character of the diet of the population under consideration may be expected to vary with the amount of family income, in the sense at least that the lower the income the more- the character of the diet will tend to approach that In this eonnection see Sydenstricker, 1915. u atrcallynl food supplies, with theexception offresh milk, were purchased (i. e., nothome-produced) during the sa3son (the late spring) of the year under eonsideraton. Households securing supplies of milk from home-owned cows have not been included in the above table (Table VII), since supples of food from s source oonstitute a faor affecting the diet of the population apart from the factor of family Income. They ar conidered In another connection. 26U91 November 12, 1920. associated with pellagra. This is confirmed by the quite definite differences in food supply ibove actually shQwn to be associated with differences in family income, and further by the fact that when comparison is made, such as Table VII and Fig. 1 permit, it is found that in a general, but quite definite, way the food supply of the house- COM1PAQ.SOt OF THE SuPPLY OF CEER-WAt A0CLESOwF6OOD IN HOUSEHOLDS WITH LowEST lCrOimEs AtiD Iti HOUt VH LOS VAVItQ Ar LvSr Two CAsrEs o0 Puwt& WITH TI*AT it HOusmoXLDS WITH V4MuESV INCOMES - £rA%Lp.

0 c65 Lz a c )O U0- .a-0UbJ0 1L0 LL30 FIG. 1. holds of the lowest-income class tends to be similar to that of the group of pellagrous households in each of which at least two cases of pellagra occurred prior to August 1, 1916; that is, similar to that of the group whose food supply more closely approximates a representative sample of a pellagra-producing diet than does any other afforded by our study. Novemkber 12. 1920. 2692

,sw%,;auuetpoJfno *suwoq I 4 I put sod. pauuuej i SmOUqSOJ~ I !;;%* { uS Isms!ptusalne _ 0 8,sSI z | 14 qswu pauuuo "4 a2 U)

0 co . 000~~~~~~~sA C Smt35- LoI 0 *qOApeUaO I I" 0 84e . . "4"4"41°C%"

m 0 SNf 4 -wlqqo2o put. Iroc O zm 4"440w CDo 4 O 88.r L ' _* _ iY'ui pusuw -ilsqns _ - I 8o;$14 I"- a~ E 01 C>+1045-' '.4 :4 "4 p4 Cs :2 ,(qnqi! Lasooa cl co 4 A.4.1 .5'i. .aKI!uj 240M '" P' CD z -: rff PU P; .4 ._

CO_C-NI '0

@3d uS N ,p,uajq'JfL0 UWOq C) E X I jil C) _ _ snjJpo! P' 54 Cs

psuueq pug sued poiJ(1 m o C-1 C)

9THA PU'S Imau19UJO :3 ,3pod uui J B: * * . . : -6 a I = I I I @ @30I : :8 0 0- Si -ociS ,-0'. p4T a)14 ;t 2693 November 12. 1920.

DIFERENCES IN NCIDENCE AMONG HOUSEHOLDS. From the foregoing, considerations the &)nclusion woul&dseem to be suggested that the inverse correlation between pellagra incidence and family income depended in large measure, if not entirely, on tho /unfavorable effect of a low income on the character of the diet. In this connection, however, it must be noted and consideration must be given to the fact that a large proportion of households with low inco'mes were iiot affected with the disease."' Thus, in the villege of In, where the highest of the incidence rates obser-ved by us in 1916 occurred and where the rate among persons constituting the households with incomes under the average was 90 per 1,000, over- 65 per cent of these poorer households appeared not to be affected, and, in varying degree, this was true of each of the seven villates studied. That the exemption of these families from pellagra was not due to a lack of subjects of "susceptible" sex is evident from what has already been said on this point; and that it could not be attributed to lack of human material of "susceptible" age appears very clearly when the distribution of the population according to age is comapared for the pellagrous and for the poorer nonpellagrous households in a representative village, as is done in Table VIII. Manifestly, therefore, the amount of family income-that is, money income (in the sense -here used), such as wages, cash payments from boarders, cash receipts from sales of supplies, and other sources-was not the sole factor determining the character of-the household diet. 19 Simirly, a large proportio of the member of pellagous households were appartly unaffected by the disease. As hs already been stated, the prsent study deals with the household, not with the indi- i¶dual,exceptingonly ds to pellagranidence We have, thereforo, no specadataon which an explanistii of the exemption of the unaffected members of a household might be based. Nevertheless, in the light of (a) certain general observations and (b) of analogies to such food defiiency diseases asscurvy and beriberi, together with (c) the knowledge gained as the result of the newer work of many Students in the field of diet and nutrition, thefollowingsuggestionsmay properly besubmitted forconsfderationin thisconnection: 1. Differences in didt consumed amoW inddviduals ofthe Aousehold-Although all members of a household presumably have thesame diet available, as the result ofindividual likes and dislikes, observable at alimost amy table, slight differences in diet actually consumed are common and marked differences, amounting i some instances to outstanding individual eccentricities,- are not rare. Furthermore, differences in die actually consumed may arise from, or be accentuated by, food eaten between meals and by supplemental foods of one kind or anotherin respect to which individuals of the same household may differconsideably. Clearly, then, a knowledge of the exact composition of the diet of a household or other dietary group does not necessarily justify the assumption of a knowledge of the composition of the diet consumed by an individual member ofsuch household orgroup. Failure toappreciatet'his, it may bonoted, has been a frequet cause ofserious error andconsequentconufsion in connection with studies offood-deficydiseases. 2. Differences in individual susceptibilitl or resista .-Assuniing identity of diet actually conmue, differences in incidence among individuals of the same hosehold or other dietary group may result from indiv-idual variation in resistance or susceptibility, which may coneivably be related to (a) an inhernt individual chiacteristic, (b) the age or sex oftheindividual, (c) tJeexlstenoofsomeexhaustingunderlying disease orcondition (hookworm, dysentery,duodeal fistula), or (d) tounlie physical strain or exerti . Combinationa qffaedora 1 and . November 12, 1920. 2694 TABLE VIII.-Age distrbution of ppt.pktim- eonotting the nonpellegrow houe- holds with lowfamily income a and the pellagrous households of the mtll tillage ofIn.

I ~~~~Agegroups. Households. ' All Under | 5-9 10-14 20-29 30I44 | v45 0and ages. 5 Ii i over.

NUMBER OF PERSON8.

Noupelou...... 265 62 531 61 331 45 14 7 Perous...... 168 31 32 49 195 1 31 Anhouseholds...... 433 83 851 110 52 76 19 a

PER CENT.

Nonpellagrous ...... 100.0 19.61 20.0 23.01 12.5 17.0 5.3 2.6 pellagros...... 100.0 18.6 I 19.0 29.2 11.3 18.5 3.0b Allhousehos ...... 100.0 19.2 19.6 25.4 12.0 17.5 4.4 1.8

"That is, under $8 per adult maleunit during a half-month period in the late spring of 1916. This is quite in accord with common experience, which teaches that there are many factors that, singly or in varying combination, -may have an important influence on the character of the diet and that may ,vary among and thus may distinguish different households of the same income. In illustration of tlis, reference may be made to the group of factors that tend to determine the amount and proportion of family income available for the purchase of food, an example of which is the occurrence of sickness or injury, making an unusual draft on the family income. Related to such factors are the general spirit of the household with respect to thrift (which, when unwisely directed, may be harmful) and the intelligence and ability of the housewife in utilizing the available family income. Mo're tangible than these, and perhaps of tore immediate practical importance in its effect on the household diet, is the difference among households with respect to the availability of food supplies. We found that, among households with similar incomes and of the same 'village and thus with accoss to the same markets, there were some more favorably situated in lhaving sources of food supplies that others either did not possess or possessed in a lesser degree. Such sources frequently were gardens, home-owned cows, swine, poultry, and the .lie.- DIFFlRENCES IN INCIDUNCE AMONG VILLAGES. Besides,differences among households with similar incomes and of the same village, quite marked differences in pellagra incidence were also observed, as has already been pointed out, among the villages themselves. We have sought to determine the explanation of this by considering in order the various possibilities that suggested themselves. November, 12, 1920. 2695 -11 (a) The general environment (except as to condition of sanitation and food supply), the origin and type of the population, the character of work, and the general habits of living among these populations being, as we have already stated, strikingly similar, do not call for consideration in the present connection. (b) Differences in -sanitary conditions among, villages were noted and their relation to differences in the-incidence of the disease was- studied without, however, discovering any consistent correlatiolf among them. Reasons have been given why hygienic and sanitary factors might be dismissed from consideration in the attempt to ex- plair the inverse correlation between family income and the incidence of pellagra."0 Further discussion of these factors in the present connection would therefore seem to be unnecessary. (c) The marked association between low family income and pellagra incidence suggested the possibility that the difference in incidence among villages might be-associated with a difference in the proportion of families of low incomes included in the populations of the several villages. But if the differences in the proportion of.the population which had low incomes in the various villages be compared with the differences in pellagra incidence, as is done in Table X, no consistent correlation is disclosed. Clearly the differences in pellagra incidence among these villages can not be accounted for by-differences in the economic status of the populations concerned. TABLE IX.-Compariaon of the relation of rate of pellagra incidence to proportion of population oflowfamily income in seven mill villages ojfiouth Carolina in 1916.

Per cent of population whose lialf-month pellag family income per rate per Village. Village. ~~~~~~~adultless than-male unit was IsationI.,OWpopw~(all incomes) in 1916. $6.00 - 8.00

Allvillages ...... 31.5 r6.5Z3.4 At ...... 37.0 64.32D.7 In ...... 40.9 66.6 _ 64.8 NV ...... 26.. 45.720.0- RC.Sn...... 3.3K.11..9. ... 13.2 23724.9k Sn. 38.3 58.1 4_0.9 Sa ...... 28.3 25.757.4 WY...... 31.064.0 18.7 Pearsonian coefficient of correlation: r-0.33±0.2- (d) As family income IS simply an index of the power to buy, and as this power is obviously limited by the cost of the thing desired (in this instance food), the thought naturally suggests itself that differences in prices in the different villages might be of importance in the present connection. That this was a negligible factor, however, is u"ee pages 2688 and 268. Wove.erIZ, 1i*20 2696'

showhi by the fact that we found -nosignificint differences in food prices in the different vllagbes. (e) That individuals of "susceptible" ages may have been present in relatively insignificant numbers in the villages among whose poorer households few if any were affected by the disease, and that this may account foi' the differences, is an explanation that may be dismissed from consideration when the age distribution of the population is compared according to village, as may be seen by reference to Table .

TABLE X.-Comparison of the age distibution qf the population constituting house. holds with low family tncomes a of sven cotton-mill villages of South Carolina.

ClsCsfied by age peiods (year).

f|Under 3| - | 10-19 20-29 30-44 4 and

NUMBER 0? PSON.

At - . 367 65 63 82 63 59 18 _ i -...n...... 433 83 85 1101527619 8 ...... 331 60 56 87 45 67 1 15 .Rc ..... 206 37 42 50s 3 32 5O an_,...... _ .. 338 65 46 69 61 62 14 31 as...... 8...... 28 51 51 68 40 34 1 10 W ...... 407 62 72 120 392417 73 Allvilloge.2, 2 417 4m 33' 383 logj 9

rim CENT.

At... 100.0 17.5 17.6 22.3 17.2 16.1 4.9 4.1 I .. .100.0 19.2 19.6 25.4 12.0 17.5 4.4 1.8 N . . 100.0 181 16.9 26.3 13.6 17.2 I4.5 3.3 e . .100.0 18.0 20.4 21.3- 16.5 15.5 2 4 2.9 Sn .. 100.0 19.2 13.6 20.4 18.0 16.4 4.1 9.2 100.0 19.0 19.0 25.4 14.9 12.7 8a..wY* ,...... 100.0 15.2 17.4 29.5 9.6 17.9 5.95.2 4.2

All villag... . 100.0 1I&0 17.7 1 24.9 14.2 16.3 4.Q 4.2

a That is under $8 per adul} male unit during a half month in the late spring of 1910. gf) We thius come to a consideration, finally, of differences among villages with respect to availability of food supplies on the local markets or from home production. More or less marked diflfrenes in this respect were found to exist. In relating these to differences m pellagra incidence it should be borne in mind that the availability to a consumer of a supply of a given article or group of articles of food is often involved in a number of interrelated conditions, the influence of any one of which may be difficult to measure. Therefore, in analyzing community conditions affecting the supply of any arti. cle or articles of food, onily the outstanding and ctearcut differences between localities can be considered. Furthermore, since even considerable differences in pellagra incidence among localities of small populatton are not necessarily a reflection of community conditions, it seemed desirable to select for the study of the relationship under 2697- November 12, 100. consideration villages presenting- the- most marked contrast in *he incidence of the -disease, thereby avoiding-the possibly confusing effects of irregularities likely to arise in attempts to relate com,munity conditions of food availability to pellagra rates for which community conditions were possibly responsible only in part or not at all. There was moreover, the compelling pr'actical consideration to thus restrict ourselves in the fact that the amount of labor involved in a detailed study of conditions in each of -our villages was beyond the physical capacity of the available personnel to perform. Accordingly we selected for study Ny village, with no pellagra, and In Village, with a rate of not less than 64.6 per 1,000 during 1916. The facts, as we were able to determine them relating to the availability of supplies of various foods in these two v'illages, are briefly summarized in the following: (1) Retail grocery establishmenth.-In both villages the mill workers' households purchased their supplies of all foods from the company stores and from grocery stores in adjacent communities, with the exception of fresh meats, fresh milk, and varying proportions of their supplies of eggs, butter green vegetables, and fresh fruits. Exclu- sive of the articles named, the availability of supplies of all foods a'peared to be the same in both villages for the reasons that (a) in both villages there existed company stores which carried in stock practically the same kinds of foods and were operated along similar lihes from the point of view of credit allowances to mill workers, and (b) within a mile of either village were general grocery stores carryinge in stock the same kinds and varieties of foods as those sold at the company stores. The company stores at Ny, however, did not sell fresh vegetables, potatoes, and fresh fruits, there being an agreement with the lessee of the village market to the effect that the latter should have the exclusive store privilege of selling these articles. A much more regular and abundant supply of fresh vegetables and fruits was available at the Ny market than at the In company store. It is of interest to note that the In households, whose-incomes wore less than the average income for the two villages, relied to a greater extenit upon the company store than the Ny households with similar incomes. This is indicated by the purchase and food supply records during the 15-day periodl from May 16 to May 30, 1916, which show that 60 per cent of the In households purchased all of their groceries (exclusive of home produce and produce from near-by farms) from the company store as compared with only 13 per cent of the Ny houseliolds. (2) Fresh-meat mrarketsi-In Ny there was a fresh-meat market which had been open seven days in the week the year round for several years. This market, as already noted, also sold fresh fruit November 12, 1920. 2698 and vegetables. The nearest other market was 1 mile away, and this market operated a wagon- which regularly had taken orders and delivered fresh meat in the,village at the doors of the mill workers' households. during the spring and the preceding fall and winter. At the town of Seneca, 4 miles away, there were two other fresh-meat markets which were occasionally patronized by Ny mill workers. In In village there was no fresh-meat market, and there had not been any since the last of February, 1916. In October, 1915, a privately operated market was opened in the basement of the company store building. This market was kept open every week day until. about January 1, 1916, but, from all accounts, it was poorly managed. For this reason and for the reason that locally producedfreshmeats became sca-ace after January 1, the market was open only one or two days a week during January and February and its credit trade was severely curtailed, being now limited to those households which had been prompt in settlements. In the latter part of February the -market ceased to be operated. In the town of Inman, a mile or more from the mill village, there was a market selling fresh meat for cash only, which had a few regular customers among the mill workers.. No other market was accessible except in the city of Spartanburg, 13 miles away. With the exception of a small amount of poultry purchased at home or purchased from near-by farmers, the sole sources of fresh meats in the two villages during the late spring of 1916 were theso fresh-meat markets. The difference in availability of a fresh meat supply in the two villages is clearly reflected in the records of actual purchases during. the 15-day period May 16-30, 1916, illustrated. in Table XI, thereby suggesting a marked contrast--in fresh-meat consumption between the two villages for households of similar incomes. (See also Table XIII.) TABLE XI.-Comparis ofavailability offresh meat as shown by the number ofpurchases and the average daily supply of thisfood during the period May 16-80, 1916, in households, withfamily incomes less than the average, of two mill villages ofSouth Carolina.

Village of .Nu. Village of In. (average daily supply per(averagteadult daily supply per adult male unit, 31.2 grams.) male unit, 7.0 grams.). .Number of purchawes dnring 1.-day period. I _ Number of Per cent Number of 1c.r cent households of total households of total purciasing. households. purchasing. households.

None ...... 17 31.0 46 8 1.. 10.96 1s 25.7 2..7 12.7 4 5.7 3.. 7 12.7 1 14 4. . 6 10.9 1 1.4 5.S. 6 10.9 0 0.0 Morethan5. . 6 10.9 0 Q0. 2699 November 12, 1920. (3) Produce fromn adaeent farm territory.-The two villages pre- sentbd a striking contrast with respzect to the availability of food supplies from adjacent farm territory. In the mill village of In there were no regular sellers of farm produce during the spring of 1916; farmers visited the village only occasionally and then practically solely in order to dispose of such goods as they had been unable to sell in the near-by town of Inman. The absence of hucksters was so marked that repeated and detailed inquiries were made of mill workers' households and of other persons living in or in close touch with the village, and the village was several times canvassed in order to secure as complete and accurate information as possible in relation thereto. Ny, on the other hand, appeared to be a center for marketing produce from near-byfarms. In addition to a number of farmers who marketed their produce in that villoge occasionally, not less than 22 farmers who habitually sold in the vil; lage at retail were found and interviewed in a single canvass of the adjacent territory. These regular hucksters came to the village once a week or ofteiier practically the year round. Of the 22 who were Interviewed, 15 sold fresh milk and butter, 10 sold eggs. 7 sold poultry, 5 sold fresh pork, 2 sold fresh- beef, and practically all of them sold potatoes and vegetaHles. Those selling milk and butter delivered regularly throughout the ycar and marketed other produce in different seasons. Thus, eggs were sold principally in the spring, poultry in the summer, autumn, and winter, fresh beef and pork in the autumn and winter, and green vegetables im the spring, summer, and autunmn. On the basis of statements made by those selling produce regularly, not less than 41,000 quarts of fresh milk (about 790 quarts weekly), 12,000 pounds of butter (about 230 pounds weekly), 1,800 dozen eggs, and 4,200 pounds of live poultry, fresh beef, and fresh pork were sold during the 12 months ending May 30, 1916. Theso totals do xnot include quantities sold by other farmers or by stores and markets. This contrast in available sources of farm produce is indicated also by the statements of actual purchases by the households in the respective villages, secured in the course of the dietary canvass. These statements have been summarized for households of similar incomes in Table XII. A striking difference is shown in the extent to which the lhouseholds in Ny and In relied upon near-by farms for supplies of certain foods. November 12, 1920. 2700 TABLE XII.-Compqrin of availability of tertain food8 in two cotton-milU villaged ofSouth Carolina, as indicated by the proportion of thehouseholda with familytnoomes under the average of the contrasted4illages purchasing the specified artcks fronm near- byfarms during the period May 16-30, 1916.

Ny. In.

Householdspur- Louseholds pur- Average chasing. Artilel¢purchLssd. quantityAverage chasing. quantity per hotise- perhouse- hold pur- _ Percont hold pur- Peent chasing. Number. of total chasing. Number. of total households. households.

Freshmilk ...... 22.5 qts. 24 51.0 29.3 qts.3 4.5 Btutter ...... 3.4 lbs. 23 49.0 4. 0 lbs. 1 1.5 Eggs ...... 2.9doz. 19 40.5 6. 0 doz. 1 1. Fresh vegotables ...... 831 6B.0 ...... I 1. 5 Fresh frit ...... 8 17.0 O 0 O Poultry ..... 4.0 lbs. 1 2.1 3.°lbs. 1 1.5

Any of the above articles ...... 40 83.3G 9.0 None ...... 8 16.76..1 91.0 The difference between Ny and In in availabilitv of food supplies from adjacent fariY territority was so pronounced that further inquiries were made into some of the underlying conditions in order to discover, if possible, what other economic factors were responsible for bringing this about. From these inquiries it appeared that at least two conditions were important in causing the difference in availability-of the supply of the foods in question: namely (a) differences in the kind of agriculture in the territory adjacent to the villages, and (b) differences in marketing conditions. The two are closely related, but for the sake of clearness it will be advantageous to dis- cuss t.hem separately. (a) Contrast in the kinds of agriculture near the two villages.-A census of the farm products in the agricultural territory adjacent to the two villages was not undertaken, but from observation in the course of several trips and canvasses in the sections in question it was quite clear that a marked contrast existed in the kinds of agriculture pursued. The territory around In-was planted principally in cotton, and relatively little diversification in crops existed. 'Truck farming on any considerable scale was not engaged in. Few beef cattle were raised and milch cows apparently were usually not more than sufficient to supply the household needs of the farmers. Many farmers had no cows or pigs or even poultry. The agriculture in the In section seemed rather typical of the cotton areas in Southl Carolina. Cotton was the predominant crop; all other products were inicidental, none of them constituting the principal output of any farm, so far as was observed. The territory around Ny, on the other hand, was exceptional for South Carolina in that a considerable amount of diversified farming was carried on, although not fully comparable in 2701 November 12, 1920. this respect with the.farsming sections in States where one-crop agriculture has not been the rule. Cotton was a relatively less important crop, and beef cattle, swine, poultry, and milch cows seemed much more abundant than in the In section. Apparently greater emphasi* was given to gardens, and the amount of truck produced was notice- ably larger. The physical character of the section apparently was one cause of this difference in products. The land around In is almost level, lies well below the foothills of the Blue Ridge Mountains, and is well suited for the growing of cotton. The land around Ny is quite rolling and even hilly, being, in fact, in the foothills of the mountains and thus not so well suited to cotton growing. Land not suitable for the cultivation of cotton and, hence, available and used for corn and truck products was consequently far more abundant near Ny than near In. (b) Conitrast in market conditions.-Conditions affecting the market for fann produce from the two sections were quite different in some important respects. The village of Ny is itself more isolated than the village of In and is not near any important community. The nearest rafilway stationI is a mile awaty and is surrounded by only about a dozen hlousea, including three small stores. Seneca, the nearest town of any size (population 1,313 in 1910), is some 4 miles from Ny, anid Greenville, the nearest city (population 15,741 in 1910), is about 40 miles distant. Seneca exports comparatively little produce and hence its market is limited to local needs which are not sufficient to absorb all the mniseellaneous farm products of the vicinity. Ny is thus a competitor for such produce as the adjacent farm territory affords. The-village itself has been in existence without much changre in size for about 25 years, and we found that some of the sellers of farm produce had been visitingf it regularly for over 10 years. On the other hand, In mill village is almost on the out- skirts of the town of Inrman (population 474 in 1910), which is on the railroad connecting Spartanburg, S. C., with Asheville, N. C. The demanids of the Inman market for farm products are far from being confined to securing sufficient supplies for the needs of its townspeople, since several resident buyers purchase the surplus produce of the adjacent territory andl ship it to Spartanburg. Since Spart&nburg (population 17,517 in 1910) is but 13 miles distant along a gooI highway, buyers from that city cover the territory aroun(l In villagc fairly tlhoroughly, and farmers having produce to market often take it to t.he city when they go there to avail themselves of Spartanburg's superior shopping advantages. The position of In village appears, therefore,- to be distinctly disadvantageous with respect to farm produce since it must compete for this not only with the town of Inman but, more important, also with the city of - November 12, 1920.2 `2702 Spartanbiirg. So far as could be ascertained in 1916, no regular trade with near-byfarms had been established, and, as has been pointed out, such casual trade as existed was only that afforded by occasional visits of hucksters who, after making the rounds in the town of Inman, lad unsold remnants of produce. (4) Home-providedfoods.-Specific inquiries were made of all mill workers' households regarding their possession of cows, poultry, -and gardens and, as far as practicable, regarding their importance lparticularly during the spring of 1916. Different proportions of thb households in the two villages were found to have such -sources of food supplies. -(a) Milch cows.-There was but little difference in the proportion of households in either village owning productive cows during the spring of 1916, the percentage being 17.2 for Ny and 23.31 for Ix among households having less than the average income. Such difference as existed in this respect was in favor of In. But it should be noted in this connection that 33.3 per cent of the In households had no fresh-milk supply at all during the 15-day period for which household supply records were kept, as against only 8 per cent of the Ny households (see Table XIV). This difference in distribution was. caused by the larger proportion of Ny households that purchased milk from hucksters, since, as shown in Table XII, 51 per cent of Ny households purchased fresh milk from hucksters as against 4:5 per cent of In- households. (b) Swine.-Slnughtering of hogs is done in autumn and -winter. This is a general practice and prevailed in Ny as well as in In;. Home-produced pork-did not figure in the spring food supply of mill workers' hQuseholds- in either village, except in the form vf cured and salt meat. Of the Ny households, 17 per cent slaughtered home- raised- hogs as compared with 33.3 per cent of In households. All of ttese househofds slaughtered their hogs before February 1, 1916, the majority in either village slaughtering before Christmas, 1915. Of the Ny households, 11 per cent cured home-slaughtered meat, as compared with 29 per cent of In households; but very little of this meat Was on hand for use -in the late spring. Inquiries of households slaughtering swine revealed the fact that in less tllan 5 per cent of such households were there any supplies of home-cured pork on hand on May 16, 1916, these beina principally salt pork. The home-produced pork, therefore, did not appear to enter mj significant degree into the spring food supply of the households in either village. (e) Poultry.-Inquiries of households having less than the average income showed that 40-per cent of the Ny households and 25 per cent of the In households either did own poultry during the winter 2703 November 12, 1920. and spring months ending May 30, 1916,- or were owning poultry at the time of the canvaw (from June 1 to June 10, 1916). The average number of poultry consumed.per household during the preceding year was 22 in Ny and 8 in In. The per cent of Ny households reporting consumption of home-owned poultry during the spring of 1916 was 19, as against 3 per cent for In. Thirty-two per cent of Ny households reported a fairly regular supply of eggs from -home-owned hens as against 21 per cent of In households. It appears that the advantage in the supplies of home-produced poultry and eggs during the preceding winter and spring lay distinctly with Ny households. (d) Gardens.-Home gardens were much more generally found in the village of In than in Ny. Nearly 92 per cent of the In households had gardens planted on June 1, 1916, as against less than 23 per cent of Ny households. The opportunity afforded by suitable garden space was decidedly better in In than in Ny; practically every home in In had a good-sized garden plot, whereas many of the *y households had no suitable. space at all. It was quite evident; however, that home gardens contributed but very slightly, if at all, to the food supply of households in either village during the spring of 1916. With the exception of an occasional t'rare" is perhaps a more accurate term) mess or dish of greens, a very little lettuce, and a-few young onions, the gardens had yielded no supplies during 1916 up to about June 1. Not until after June 15 did garden produce become abundant, a condition that was somewhat contrary to the expectation of the authors, who had anticipated finding considorably earlier garden production in this section. The principal reason for this tardiness appears to be the fact that gardens m mill villages are usually planted later than gardens elsewhere in this section. Difficulty in getting the ground prepared early enough, owing in part to the fact that the long hours of work in the mill leave no available daylight for gardening until well along in the spring, lack of initiative in making other preparations, and possibly other causes, apparently almost preclude good early spring gardens in most of the mill villages studied, including N7y and In, although climatic conditions ordinarily are such that gardens can be made to yield supplies of early varieties of vegetables during May and even in April. Aside from a half dozen households reporting that they had had radishes, lettuce, or English peas, only about one-third of the In households reported that they had had greens or young onions even occasionally and in small quantities before this date. In Ny the proportion was even less. Summing up the principal differences in availablilty of food supplies during the spring of 1916 as between Ny and In, it may be said November 12, 1920. 2704 that (1) supplies of freslh milk, butter, green vegetables, aind -fresh fruit were available to a greater degree (better distributed among the households) in Ny than in In, because, in the farm territory adjacent to Ny, there was a larger production of these articles of food and because Ny occupied a more advanitageous location as a market for such products, and (2) that a supply of fresh meat was aavailabje to a greater degree in Ny than in In because of the existence of a fresh-meat market in Ny all the year around. In -practically all other respects the availability of food supplies appeared to be generally similar in the two villages. The conditions outlined above are reflected in a comparison of the total food supplies (luring the 15-day period May 16-30, 1916, of hlouseholds in Ny and In. In this comparison (Tables XIII and XIV) in order to eliminate as far as practicable the influence of differences in economic status, only those households with less tllan tlhe average of incomes21 have been considered. In Table XIII is shown the averaige quantity of eaclh article of food for all the households considered. Inasmuclh as an "average" affords no idea of the vitally important factor of distribution, we have prepared Table XIV in which are shown the percentages of the households in each village which had various quantities of each article -of food, such quantities be,ing expressed in terms of the average for all houselholds in order to shorten the statistical pre- sentation. The two tables should be considered together in comparing the supplies of any article of food. This comparison indicates that during the 15-day period, May 16-30, 1916, (1) supplies of fresh meat, fresh milk, green vegetables, and fresh fruit were more abundant (i. e., better distributed) iR Ny-than in In households; (2) supplies of cured and canned meats, salt pork, butter, flour, lard, and lard substitutes, and dried peas and beans in Ny households were quite similar to those in In households; and (3) supplies of eggs, corn meal, Irish potatoes, and most canned goods were- more abundant in In than in Ny households. Other differences in the supplies of articles of food occurring either rarely or in small quantities are indicated. 21 The average half-month family income per adult male unit for all householls NYY and1 ln was $7.99. Hence all households with such incomes under $8 were considerel. 2705 November 12, 1920. TABLE XIII.-App ema average daily supply ofvarioufoods in households of&itton- mill operatives during the 15-day period May 16-3O, 1916, paredfor the villags o1Ny and In, South Carolina. [All households considere-l h3ve inaome3 of less than thqsavervze of the total households of both villges (less than $8 per adult male unit durinu the 15-day period).) Average suipply per adtilt male Ratloof unit in grams suplI Article of food. per day. of In to hou.soNV Ny-a In.b hol

Fresh meats ...... ' 34 7 OL 21i Cured leanmc3s ...... 24 20 .83 Cauned meats ...... 19 17 .89 Eggs...... 34 50 -1.47 Fresh milk ...... 426 457 1.07 Preserved milk: ...... 1 3 8.00 Butter ~ ...... 26 30 1.15 Cheese ...... 3 (C) ...... Dried peas and beans...... 32 _ 25 .7 Canned peas and beas...... 2 4 2.00

YVheatWheat floredflour ...... ae,adcak ...... 1 358...3518 - 358 1.00 uCorn mal ...... 1398 13 Grits..-. 4 2 ..50 Cnnedorn. . . .3...... 19.. 3 Rice ...... 4 5 125 ealtpork ...... 63 090 LaRind...... substituts. lar 41 4 9 areenstrink beans.. . . i; 1 .09 Cannedstring beans ...... 1 4 4.00 Green vegetables ...... 88 46 .62 Canned v egetables ...... 36 36 1.00 . CanndFresh fruitsvepitals...... 4036 3620 8 .50.6 DriedFrnesh fruits ...... 1240 208 2 .QD.61- Canned fruitss...... 10 20 2.00 Irish potatoes...... 34 60 1.76 Raw sweet potatoes ....0 0...... Canned sweet potatoes... 5 3 .60 Sugar ..46 39 . 85 Sirup ...... 17 17 1.00 Jellies and jams ...... 3 9 too All other foods (cost in cents) ...... 2 1 .50 a 48 households composed of 210.3 adult male units. Data were available for the following niurib. of adult male units for trie foods spscided; Salt pork and drial fruits, 206.2; Irish potatoes, 205.7; wheatilour, 160.2; corn meal, 204.0. 1 67 households composed of 2S7.4 adult male units. Data were available for the ollowing number of aduit male units for the foocds specifed: Fresh milk and butter, 257.4. Less than 0.5 gram. 157120 20 - 3 Nlovember 12, 1920. 2706 TABLB XIV. Percentages of cotton-mill operatives' housswlds having supplw of varius articles offood in ierent quantites per adult mae unit per day, compaSre for 1/e mill villages of Ny and In, South Carolina. [All households considered have incomes of less than the average for the two viulages

*Per cent of households whose average daily supply per adult male unit was- Average daily supply Some, but One-third The Article of food. Village per less than or more, average or adult one-third but less more than male None. of the than the the unit. average of average of average of all house- all house- allhouso- holds. holds. holds.

Grans. VI 3 3.2 6.2 16.7 & Fii~Fres~~~~~~~hmeatsmeats...... {I...... 4 9. 24 37.5 { 4.2 27.1 31.2 CuredlIcanmeats ...... 20 Cae¢NYmeats...... 466.&0 14.9. 3218 ..N . 19 22.9 10.4 37.5 29.2 Canned meats ...... 17 35.8 3.0 31.3 29.9 { ... 34 31.2 4.2 31.2 33.3 Eggs ...... hi.... 50 7.5 6.0 26.9 50.7 426 .3 10.4 45.8 5 4 Fresh milk ...... Fresh milk.lIn~~~~~~....{In .. 457 -33.3 0.0 30.2 36.5 I ...... 1 .5 - 6 2.1 8.3 rmerved milN1Preserved...... milk...... 5.~~~~~~~~TIn~3 73.6 1.5 1. i. 22.4 Butter.Ny. . . . . X26 16.7 10.4 33.3 39. & ;...In 30 14.9 16.4 21.4 46.3 Cheese ...... {In:::. . 3 f.5 2.1 0:0 10.4 Dned (a) 9.0 0. 3 28 463.06 32 25.0 14.6 20.8 39.6 Driedpeasandbeans ...... u...... I 25 32.8 7.5 29.9 29.9 ... 2 83.3 0.0 0.0 167 CanncdCancdpespeas adand beanseas...... Ny ~ k ..... 4 85.~1 0.0 0.0 14.9 .... 0.0 43.7 29.2 Wheat flour ...... Nyun ~~~~358358 18.56.2 3.1 32.3 46.2 Wheat bread, cakes;and crackers...... N 13 18.7 12.5 33.3 35.4 ...... 18 25.4 6.0 22.4 46.3 Cornmeal_ ...... Ry. 139 29.8 4.3 29.8 36.2 ..... 180 20.9 10.0 17.9 61.2 ivy.... 4 87.5 0.0 0.0 12.5 Grits...... 4Grits 560.80° I0n 95.6 0.0 0.0 4.5 ..2~~~~~~~~ft..... A 1e ice ...... 4 75.0 0.0 0.0 25.0 .. ... 5 70.0. 0 0.0 29.9

...... 54 4.3 Sa1t&pork.JNyBatpork . Intin ~~~53 10.4 4.30.0 41.857.2 34.47.80 N.. 41 6.2 4.2 52.1 37.5 lardi~randadlarda-r substitutes.sbsittes...... 40 10.4 3.0 37.3 49.3 --- 11 31.2 Greenstringbeans ...... I100.0 Q00 100.0 0.0 0.0 2.1 Canned stringbeans 1 0..975 0.0 0.0 10.5 Green v-egetables (bought).NY 88 14.6 12.5 39.6 33.3 Irn .... 46 22.7 16.7 37.9 22.7 Other canned vegetables.I. 36 29.2 2.1 22.9 45.8 In .... 36 26.9 7.5 28.4 37.3 Fresh fruits.Ny 40 25.0 10.4 20.8 43.7 in ... 20 43.9 9.1 28.8 18.2 Driedfruits ...... Ny 12 53.2 0.0 17.0 29.8 In .. 8 70.2 1.5 6.0 22.4 Cannedfruits .. Ny . 10 66.7 0.0 2.1 31.2 In ~~~~2056.7 0.0 1.5 41.8 Irishpotatoes .N...... 34 45.8 4.2 20.8 29.2 In ~~~~6053.7 3.0 3.0 40.3 Fresh sweet potatoes .Ny . 0 0.0 0.0 0.0 0.0 In .. 0 0.0 0.0 0.0 0.0 Canned 'sweetpotatoes...... Ny .... 5 81.2 0.0 0.0 18.7 1in .... 3 88.1 0.0 d.0 11.9 46 10.4 4.2 45.8 39.6 Sugar...... lIn ...39 9.09.0 43.3 38.8 Sirup ...... j!V...... ; 17 68.7 0.0 2.1 29.2 tIn .... 17 64.2 0.0 a.0 35.8 70.2 0.0 4.3 25.5 and idlliesand...... jams. . JNy ~~~~~~~~3~ Jellies jams 9 40.3 1.6 0.0 5.2

_ Lessthan 0.5 gram. 2707- November 12, 1920.

From the foregoing considerations it clearly appears that the character of the household food supply in the two villages was con- sIderably influenced by -the availability of certain foods, notably fresh meats, fresh milk, green vegetables, and fresh fruits, all of which were relatively less abundant or less equally distributed in In than in Ny. It is clear also that these differences in the food supply of Ny and In households are quite similar to the differences which, as already reported, we found to exist in the food supply of nonpellagrous and of pellagrous households.22 We have here, therefore, a striking and significant correspondence between the differences in the availability of certain foods (and thus, it is permissible to assume, in the character of the diet) in the two villaes, on the one hand, and the difference with respe.ct to the incidence of pellagra among their households on the other. Since between these two villages no other differences to which significance could properly be attached were disclosed by our study;- the conclusion would seem to be, warranted that the difference in the availability of food sup. plies above summarized was the outstanding determining fictor in relation to the marked difference in the incidence of the disease. Thus, of all the factors we have studied in relation to differences in pellagra incidence anmong our villages, the factor of food availability is the only one in connection with which significant evidenee of such relationship w'as found. - The-conclusion would, therefore, seem to be warranted that in this factor we have the explanation for the differences among the villages studied in the incidence of the disease, so far as this incidence was a reflection of communiity conditions.23 2' Goldberger, WVheeler, anid Sydenstricker, 1918: also 1920a. 2S If such factor as food availability operted to effect the rate of pellagra Incidence in our villages, then It may be reasonably cxpected that in the locality with exceptionally unfavorable conditions of food availability, family incomc wouild be less efficient as a protective factor than in other similar localities with better conditions of food availability. With a view of testing this we prepared the following table, in which the pellagra incidence rate for each of our income classes of In village in which, we believed food availability conditions were least favorable, is compared with that of a group of five villaggs in which conditions in respect to food availability are believed to have been better. It may be seen that (1) the incidence rate in those income groups in which a significant number of cases occurred was decidedly higlher in In village: and (2) that the curve of incidence shows a highly suggestive tendency to extend to a higher plane of income in Ina village than in the group of five villages. The indications thus afforded would, therefore, appear to be consistent with and to bear out the assumption which the table -was prepared to test. Pellagra incidence according to family income in In mill viflage compared with that in a group of firea other dill villagcs of South Carolina during 191G. IRate per 1,003 of popuilation elassiried according to a half-month's family income per adult male unit in- May or June, 19116. Only derinite cases of pellagra with onset after a residence of not less than 30 days in specified villaae or in a membier oi group considered.] Number of pel- Rate per 1I000 of Numberofpesons. lagrins. population.

In. ome group. | Five In other In other In other villages. villages. villages.

All incomes...... 51 2 78543 19 Under S6 ...... 266 856 27 29 le Z 34 S647.99 . .167 730 10 15 60 21 543.99.. 118 E06 5 6 42 12 10413.99.. . . 74 499 1 2 14 4 S14and over. 26 194 0 1 0 5 a Village Ny not considered, no pellagra, as above restricted, having occurred in 1916. November 12, 1920. 2708 nIV. DISCUSSION. From the data presented in the foregoing pages it is evident that a variety of factors of an economic nature, through their effect on the character of the household diet, had an important influence on the incidence of' pellagra in the communities studied. Among these factors family income and food availability stand out most con- spicuously. As has been seen, the data presented reveal a very marked inverse correlation between family income and the incidence of the disease. Whesn it is recalled that the range of income enjoyed by our families was small (see pp. 2683, 2685), that the amount of income of even the highest of our income classes was actually quite low (but fewha~d annual incomes of over $1,000), the reduction of incidence to the point of practical disappearance of the disease in this income class is all the more striking and significant. It would seem quite impressively to indicate that the occasional occurrence of the disease in well-to-do individuals must be regarded as a relatively quite exceptional occurrence, and that the explanation of such occurrence must be sought in circumstances of a special or exceptional character. Cases in the well-to-do, instances of which have been observed repeatedly since the time of Strambio (1796), are of more than ordi- nary interest because-of the perplexity and confusion to which they tend to give rise with respect- to the etiology of the disease. Favor- able economic status of the individual tends to create the presumption that diet can have little or no etiological significauce, since there cui be no question of the ability of such individual to provide himself wiih a' liberal diet. Natural as this presumption may be under the circumstances, it nevertheless involves danger of serious error. This resiilts from the implied assumptions that because of financial ability, not only was a satisfactory diet available, but that such was also consumed. Even granting what is not necessarily the case, that financial ability to provide may be assumed to be invariably synonymous with the actual provision of a good diet2' and that a liberal diet was actually available to the individual, it by no means follows that such diet was in fact consumed. For such assumption would totally ignore the existence of individual likes and dislikes, more or less marked ,examples of which may be observed at almost any,family table. A great variety of causes may operate to bring about individual peculiarities of taste with respect to food. They may have their origin in the seemingly inherent human prejudice against the new and untried food or dish; they may date from some disagreeable 4 In thb connecti the following from Roussel(1866, pp. 430-431) is of Interet: "Almet all the inE vidualhistores, found In the literature ofpellagra in the well-to-do, are remakable becau oftLhscwsat fact * s * namely, that becauso of some misfortme or by reas a me tmwholeome twat (mm. veshaitu), such as avarice, thes well-to-do or wealthy pelir istedlu exmiy as did to poor pellagrhs about them.." 2709 2November 1;, 1920. experience associated with a particular food; they may arise as the result of ill-advised, self-imposed, or professionallr, directed dietary restrictions in the treatment of digestive disturbances, kidney disease, etc.; they may originate as a fad; and in the isane they mal arise because of some delusion such as the fear of poisoning, etc. The individual peculiarities of taste which may thus arise have a significance in relation to pellagra that has been but little appre- ciated until recently (Goldberger, 1914 and 1916). In much the greater proportion of a moderate number of cases in well-to-do individuals with a good diet presumably available, coming under our observation, a significant eccpntricity in diet c-ould readily be determined (unpublished observations). Vedder (1916, pp. 157-160) and Roberts (1920) have reported observations of a similar character. It is of interest to note also that analogous facts have been recorded in connection with beriberi (see Vedder, 1913, pp. 154, 156, 171, 180, 184). Therefore, in seeking- to explain cases of pellagra. in ilndividuals believed to have a good diet available, this factor mu'st be given due coinsideration. With conditions (including labor supply) in the cotton-milling industry substantially stable, family income may, in general,' be expected to fluctuate but little from year to year. With condions unsettled, family income may either fall or rise verv considerably; a depression, accompanied by increasing unemployment and, possibly, reductions in wage rates will be reflected in a reduced family income, while 'iidustrial prosperity, with a diminution of unemployment and, possibly, increased wage rates, will be reflected in larger famidly income. In the former event we may have a diminution in family income to the point of inability to provide the family with a proper diet, with a consequent danger of the development of pellagra and thus with a more or less marked rise in the incidence rate of the disease. In the latter event we have the opposite effects, with a tendency to a reduction in or practical disappearance of the disease. In this we have, we believe, an -illustration of the manner of operation of one of the most powerful factors in relation to the endemic and epidemic prevalence of the disease. Through its effect on diet, economic status is also an important element in, if not the entire explanation of, the oft repeated observation of the occurrence of a marked increase in the incidence or the development of an epidemic of the disease following on crop failure 25 (Weiss, P)14, p. 327) or other cause of "hard times," as was actually observed in the United States in 1915, following depression consequent on the outbreak of the World War in 1914, and as there is some reason to fear may again be observed in the spring of 1921 if the present depression, ' It should not be forgotten that overproduction, by glutting the market,may affect family income (of thefarmer) asdisastrously as may crop fallure. November 12, 1920. 2710 especially in the price of cotton and cotton-textile manufacturing, continues. At this juncture it may be well to point out that f.amily income should always be considered in connection with living (food) costs if confusion and error are to be avoided. It is the purchasing power of family income that is significant aud not necessarily its absolute amount. IAlthough economic status (as typified by family income) is, ordinarily, perhaps the most important factor (particularly in industrial communities) in relation to fluctuation in incidence of pellagra in different years,26 marked changes in food availability conceivably play a similar r6le (particularly in agricultural communities). The reported occurrence, in some localities, of a sharp increase in the prevalence of the disease following an epizootic among swine or cattle (Niederman, Konrad, and Farkas, 1898) or after the loss of these through floods, we believe, is to be explained, in part, at least, in 'this manner. X The very great importance of food availability in relation to pellWa prevalence seems heretofore not to have been very clearly recognized. Under some corcumstances, as we have shown, this factor may operate notably to affect the character of the diet and thus the incidence of the disesase. Our data dealt with differences in availability be- 'tween localities of relatively small area, but it is readily conceivable that analogous differences may exist between areas of great extent such as there is reaon to believe actually is the case between the northern and southern parts of the United States. This difference is:probably an important factor (together with the well-known dif- 'ference in dietary habit, Sydenstricker, 1915) in the notable ine- quality in the incidence of the disease in these two sections of the country. The results of the present study clearly suggest fundamental lines -along which efforts looking to the eradication of the disease should be directed, namely,, (1) economic, by improvement of economic status (income), and (2) food availability, by improvement in availability' of food supplies. Measures for improving the economic status of those people most subject to the disease, are in the main, outside of the sanitarian's sphere and but little subject to his influence. While much the same may be said to apply to the conditions of food availability, this field is more easily accessible, both directly and indirectly, to his activities and influence. Thus, for instance, by avoiding ill-considered regula- tions goveming milk production he can, negatively at least, favor an adequate supply of this invaluable food. Furthermore, he can and E We hope to consider thereiatlon of economic status to the of the d om yer to year i aseparatepaper. 2711 November 12, 1920. should aid in improving the conditions of food availability by lending his powerful influence in support of and, by cooperating with, the agencies at work in this field, in their efforts to stimulate milk pro- ductlon (particularly through cow ownership) and to induce the farmer to adopt a suitable system of crop diversification. And in this connection it may perhaps be remarked that certain preliininary observations have created in our miinds a rather strong suspicion that the single-crop system as practiced in at least some parts of our southerin States, by reason of apparently unfavorable conditions of food supply and of other conditions of an economic character bound up therein, will be found indirectly responsible for much of the pellagra morbidity anld mortality with which local agricultural labor is annually afflicted. Although considerable study will be required to (letermine defi- nitely the factors responsible for the high incidence of the disease in the rural areas in question, it would, nevertheless, seem to be the part of wisdom to make an earnest effort to iinprove conditions in the ways su,ggested above. V. SUMMARY AND CONCLUSIONS. 1. In the present paper are reported the results of thle part of the pellagra study of cotton-mill villages, during 1916, dealing with the relationi of coniditions of an economic niature to the incidence of pellagra. It is the first reported study in which the degree of the long-recognized associationl betweenl poverty and pellagra incidence is measured in a definite, purely objective manner. 2. The study was made among the white mill operatives' households in sevenl typical cotton-mill villages of South Carolina. Pellagra incidenice was determined by a systematic, biweekly, house-to-house canvass and search for cases, only. active cases being considered. In- formation relating-to household food supply, family income, etc., was secured by enumerators for a sample section of the period April 16 to-June 15, assumed to be representative of tlhe season during which the factors favoring, the production of pellagra were assumed to be most effective. 3. Family income was made the basis of classificationi according to economic status, the Atwater scale for food requirements being used for computing the size of families in comparing their incomes. 4. In general, pellagrat incidence was found to vary inversely according to family incoine. As the income fell, the incidence of the disease rose and showed an inereasing tenidenicy to affect members of the same family; as the income fell, incidence fell, being reduced almost to the point of practical disappearance in the highest of our income classes, although the income enjoyed by this class was comparatively quite low. November 12, 1920. 2712 5. The inverse correlation between pellagra incidence and family income depended on the unfavorable effect of low income on the characte-r of the diet; but family i-ncome was not the sole factor determiniing the character of the houselhold diet. 6. Differences in incidencn among households of the same income class are attributable to the operation of such factors as tend to determine the.amount anid proportion of family income available for the purchase of food, the intelligence and aibility of the housewife in utilizing the available family income, and to the differences among households with respect to availability of food supplies from such sources as home-owned cows, poultry, gardens, etc. 7. DiffLrences in incidence among villages whose corstituent households are economically similar, are attributable to differences among them in availability of food supplies resulting from differences (a) in the character of the local markets, (b) in the produce froin adjacent farm territory, anid (c) in marketing conditions. 8. The most potent factors influencing pellagra incidence in the villages studied were (a) low family income, and (b) u'nfavorable conditions regardin(g the availability of food supplies, suggesting that under the conditioiis obtaining in some of these villages in the spring of 1916 many families were without sufficient income to enable them to procure an adequate diet, and that improvement in food availability (particularly of milk and fresh meat) is urgently needed in such localities. ACKNOWLEDGMENTS. We desire to express our grateful appreciation of the valuable cooperation accorded us by the medical practitioniers, mill officials, and families of the mill operatives in the localities studied. We are indebted also to Statistician W. I. King, United States Public Health Service, for helpful ciiticisms and suggestions and assistance in the preparation of some of the tables. VI. REFERENCES. 1915. Atwater, W. O., Principles of Nutrition andl Nutri-tive Value of Food: U. S. Dept. of Agric., Farmers' Bull. No. 1042, 1915, p. 33. 1903. V. Babes, Ueber Pellagra in Rtumanien: Wien Med. Presse, 1903, vol. 44, pp. 1184, 1239. 1890. Berger, L., Pellagra: Wiener Klinik Wien, 1890, vol. 16, pp. 161-179. 1919. Boyd and Lelean, Report of a Committee of Enquiry Regarding the Prevalence of Pellagra Among Turkish Prisoners of WVar. Alexandria, Egypt, 1919. Also Jour. Roy. Army Med. Corps, 1919, vol. 33, p. 426 et al. 1870. Calmarza, J. B., Memoria sobre La Pelagra, Madrid, 1870. 1870. Casal, Obra Postuma del Dr. Casal Publicada en 1762: Corresp. Medl., Madrid, 1870, vol. 5, p. 78. 1910. Gaumer, Geo. F., Pellagra in Yucatan: Trans. Nat'l. Conf. on Pellagra, Colum- bia, S. C., 1910, pp. 101-107. 2713 Novembr 12, 1920. 1914. Goldberger, Jos., The Cause and-Prevention of Pellagra: Pub. HealthNReports Washington, D. C., Sept. 11, 1914, vol. 29, pp. 2354-2357. Als6Reprint No. 218 from Puib. Health Reports. 1916. , Pellagra-Causation and a Method of Prevention: Jour. Am. Mled. Assn. Feb. 12, 1916, vol. 66, p.p 471-476. 1918. Goldberger, Wheeler, and Sydendstricker, A Study of the Diet of Nonpellagrous and of Pellagrous Households, etc.: Jour. Am. Med. Asn., Sept. 21, 1918, vol. 71, pp. 944-949. 1920a , -, and -, A Study of the Relation of Diet to Pellagra Incidence in Seven Textile-Mill Communities of South Carolina in 1916: Pub. Health R& ports, Washington, D. C., Mar. 19, 1920, vol. 35, pp. 648-713. 1920b. -, , and , Pellagra Incidence in Relation to Sex, Age, Season, Occu- pation, and "Disablin,g Sickness" in Seven Cotton-Mill Villages of South Carolina during 1916: Pub. Health Reports, Washington, D. C., July 9, 1920, vol. 35, ppy 1650-1664. 1920c. , - and -, A Study of the Relation of Factors of a Sanitary CbiAractor to Pellagra Incidence in Seven Cotton-Mill Villages of South Carolina in 1916: Pub. Health Reports, Washington, D. C., July 16, 1920, vol. 35, pp. 1701-1714. 1829. Hameau; Note sur une maladie peu conilue observ6e daw les environs de la teste (Gironde): Jour. de Med. Prat. (etc.) de la Soc. Roy. de Med. de Bor- deaux, 1829, voh 1, pp. 310-314. 1820. Holland, Henry, On the Pellagra, A Disease Prevailing in Lombardy: Med. Chir. Trans., London, 1820, vol. 8, pp 313-346. 1903. Huertas, F., La Pelagra en Espafla: Arch Latin. de- Med. y de Biol., Madrid, Oct. 20, 1903, vol. 1, pp. 9-15. 1917. Jobling and Peterson, The Epidemiology of Pellagra in Nashville, Tennessee, II: Jour. Infcc. Dis., August, 1917, vol. 21, pp. 109-131. 1846. Lalesque, Actes de l'Acad. Roy d. Sc. (etc.) de Bordeaux, 1846, p. 421. 1907. Manning, C. J., Report on Certain Cases of Psilosis Pigmentosa Which Have Recently Occurred at the Lunatic Asylum. Barbadoes, 1907. 1898. Niedennan, Konrad, and Farkas, A Report on Pellagra in Transylvania (ab. stract), Lancet, London, July 16, 1898, vol. 2, p. 164. 1899. Von Probizer, Die Pellagra: Die Heilkunde, Wien, December, 1899, vol. 4, pp. 139-142. 1920. Roberts, S. R., Types and Treatment of Pellagra: Jour. Amer. Med. Awn.; July 3, 1920, vol. 75, pp. 21-25. 1894. V. Rosen, 11., Ueber die Pellagrm in Russland, Petersburg, Med. Wchnschrft. 1894, n. F. vol. 11, pp. 21-23. 1845. Roussel, Th., La Pellagre, Paris, 1845. 1866. - , Trait6 de la Pellagre, etc., Paris, 1866. 1903. Sandwith, F. M., How to Prevent the Spread of Pellagra in Egypt: Lancet; London, March 14, 1903, vol. 1, p. 723. 1913. Siler and Garrison, An Intensive Study of the Epidemiology of Pellagra: Am. J. Med. Sc., Philadelphia, July and August, 1913, vol. 146. 1909. Sofer, T., Die Pellagra in Oesterreich und ihre Bekampfung als Volkskrankheit: Therap. Monatshefte, April, 1909, vol. 23, pp. 216, 219. 1796. Strambio, G., Abhandlungen ueber das Pellagra, Leipzig, 1796. 1915. Sydenstricker, Edgar, The Prevalence of Pellaogra-Its Possible Relation to the Rise in the Cost of Food: Pub. Health Reports, Washington, D. C., October 22, 1915. Also Reprint No. 308 from Pub. Health Reports. 1919. Sydenstricker, Wheeler, and Goldberger, Diabling Sickness Among the Popu- lation of Seven Cotton-Mill Villages of South Carolina in Relation of Family Income: Pub. Health Reports, Washington, D. C., November 22, 1918, vol. 33, pp. 2038-2051. November 12, 1920. 2714 1913. -Vedder, E. B., Beriberi, New York, 1913. 1916. -, Dietary Deficiency as the Etiological Factor in Pellagra: Arch. Int. Med., August, 1916, vol. 18, pp. 137-172. 1914. Weiss, Ettore, Die Pellagra in Sudtirol und Die staatliche Bekampfungsaktion. Das Osterreichische Sanitsitswesen, Wien, Mlay 7, 1914, vol. 26, pp. 309-331: 1919. White, R. G., Report on an Outbreak of Pellagra Among Armenian Refugees at Port Said, 1916-1917. Cairo, Egypt, 1919.

INSTITTE ON VENEREAL-DISEASE CONTROL AND SOCIAL HYGIENE. Washington, D. C., November 22 to December 4, 1920. With the cooperation of the Interdepartmental Social Hygiene Board and the American Social HIygiene Association, the United 'States Public Health Service will conduct an Institute on Venereal Disease C(ontrol and Social Hygiene in Washington, D. C;, NTovember 22 to December 4, 1920. The institute will be held in-the New National Museum of the Smithsonian Institution and. will immediately precede the All-America Conference on Venereal Diseases, which will meet December 6-11.1 Aim of the Institute. During the years immediately preceding and following the World War, rapid progress has been made in the UTnited States in the control of venereal diseases. This progress has been due to an increase in knowledge and experience and to an increase in the niumber of persons devoting their-time to the many and varied aspects of the problem. Progress has been so rapid that there are many persons employed in one capacity or another in the attack upon venereal diseases who feel keenly a need for more informiation in the various sciences which have contributed to recent knowledge-and experience. Others desire to get into personal contact with those who are recognized as the highest authorities on various scientific and professional phases of the problem. ,Medicine, surgery, biology, psychology, and sociology now have much to contribute to the understanding of this most coinplex health problem, and there are now available, as there have never been before, eminent specialists in these various fields of knowledge from whom- instruction may be obtained. In conducting this institute on venereal disease -control it has been the aim of the Public Health Service to organize a staff of instructors comprising the ablest men and women in those subjects related to the control of venereal diseases, so that health officers, IAn account of the All.AmericaConference on Venereal Diseases, with an outline program, was published in the Public Health Reports september 17, 1920, pp. 2202-2204. 2715 November 12, 1920. private- practitioners, educators, psychologists, sociologists, and others concerned may come for'a short period of intensive work. and supplement their knowledge in such a way as to make themselves more efficient in their work. Calendar.

November 22, 9 a. m ...... Registration. Opening asembly. November 23, 9 a. m ...... Lectures begin. November 25 ...... Dinner and recreation (Thanksgiving Day). December 4 ...... Final lectures and reviews. List of Courses. [Courses will be conducted at 9, 10, and 11 a. m., and at 1.30, 2.30, and 3.30 p. m. FULL COURSES. I. The diagnoss and treatment of syphilis. II. The diagnosis and treatment of gonorrhea. III. Advanced course in the treatment of syphilis and gonorrhea. IV. The delinquent and the law. HALF COURSES. V. Diagnoss of the mental condition of delinquents. VI. Sex in education. VII. Protective work for girls. VIII. Clinic nursing and social work. IX. Heredity and eugenics. X. Sociology and social hygiene. XI. Methods of public education. XII. Methods of law enforcement. XIII. Sex psychology. XIV. Clinic management. Admisson. Officers of State and city boards of health, clinicians, laboratory technicians, nurses, social workers, police matrons, policewomen, superintendents of eleemosynary institutions, judges and probation officers of courts of domestic relations and juvenile courts, chiefs of police, medical officers of commercial inistitutions, urologists, derma- tologists, gynecologists, neurologists, psychologists, and officers of medical and social organizations are eligible for admission to the institute. Registration. Applications for admission to the institute shou7d be rnade immediately in order that the Public Hoalth Service may intelligently prepare plans for adequate lecture halls and staff ot instructors. Applications will not be accepted after November 15 without the special consent of the director. Applications, however, may be. November 12, 1920. ' 2716 mailed immediately with the understanding that they may be with- drawn if unforeseen conditions later prevent attendance. No tuition fee ig charged. The institute has been made possible by the generous cooperation of nmembers of the faculty. The following is a statement of the Surgeon General: Within a comparatively short time, those persons responsible for the public health and welfare have become aroused to the seriousness of the venereal (liseases and to related problems of social health. As a result there has been a rapid development of expert and technical knowledge, both through special research and through the cumulative experience of those who have had to deal with the specific details that these problems present. Unfortunately, this knowledge is too largely confined to a relatively few specialists. The thousands of earnest wlorkers in dispensary and clinic, in court and institution, have not had the time nor the guidance to become familiar with it. Furthermore, because of the great demands upon the workers in these fields, specialization has gone so far as to separate many who oight to be working in the closest cooperation and in perfect accord as to aims and methods. The need for instruction of a kind that only these specialists can give, the need for inspiration that only the leaders in their respective fields can contribute, and the need for exchange of thought, view- point-and experience-all these needs can admirably be met by the gathering together of the men and women who are the agents of society in promoting its health and welfare. --Such gatherings are provided in the All-America Conference on YVenereal Diseases and by the Institute on Venereal Disease Control and Social Hygiene immediately precedling. The one is primarily a conference, the other is essentially a school for intensive study. This most advanatageous combination of events affords an unusual opportunity for physicians, social workers, and all others engaged in the work of venereal-disease control. HUGH S. CUMMING, Surgeon General, United States Public Health Service. For further information regarding the Institute, address the United States Public Health Service, 16 Seventh Street SW., Washington, D. C. For detailed information regarding the All-American Confer- ence, address the Executive Secretary, All-America Conference on Venereal Diseases, 411 Eighteenth Street NW., Washington, D. C. 2717 November 12,1920. PRINCIPAL CAUSES OF DEATH, AUGUST 'AND SEPTEMBER, 1920. The accompanying table is reprinted, by permission, from the Statistical BuLl.tin of the Metropolitan Life Insurance Co. for Octo- ber, 1920. The figures are based on a strength of approximately 13,000,000. Although these rates apply to a selected group, they give compara- tive mortality conditions for the periods covered. Death sates (annual bansi) per 100,00 fo prinnapal caues, August and .Septentber, 1920, andyew 1919. [Industrial Department, Metropolitan Life Insurmace Co.]

Rate per 100,O003liesevosed. Cause of death. t.1920. Aug. 1920. Year 1919.

Total, all causes ...... ,.. 75). 5 817.9 1. 0O3.0 Tyhoil] feve x,r,...... , 10.9 8.2 7.3 es...... 1.43.2 . . Scarletfever ...... '...... 1.9 3.2 ,.9 Whoopingecoigh . . . -4.8 0. % .. iphtheria . . . 12.0 12.1 .ii.9 InMlotn.a_ .4.2 5.8 .9 Tnlhrrcu..sis (all ..r.... ,111.3 120. 1 15%.5 Caner ...... 66.. 5 67.4. 67.0 Mepingitis (all forms) ...... 5.4 6.1 6.4 Cerebral hemorrhase ... . 47.7 1.0 8 9 emrjanic diseaws of .eart ...... 90. 0 113.9 95.0 Pneuimonia (all fUirms .. . 26. 1 31.7 117.2 (Ot-er resniratory diseases . .11.3 12.1 17.0 Diarrhea and enteritis . . .27.8 30.2 16.9 Prihtits diseave . . . ,3.46 60.7 73.5 Ptierreral stat . . .15. 9 20.0 20.0 Suicides . . .5.,3 5 9 6.8 omicides ...... 84 6.8 6.9 Otlher exterral causes (exeluiding suiicides and lhomieides). . 59.9 89.476.2 1raumatism by automobile ...... 13.4 14.5 10, War deaths...... () ...... (1) )Ii All other causes .. . .17. 3 195.5 184 0 Less than O.5 per 100,000. The mortality rate continued low for the mo,nth of September. The general rate, 7.5 per 1,000, represents a declino of 8.2 per cent from that for August. It is not only the lowest rate recorded during the first nine months of 1920, but it is stated that it is lower than that for any month on record in the history of the company. The death claims paid per 1,000 policies in force (annual basis) among this group for the years 1918 and 1919 and for the first nine months-of 1920 were as follows:

Year. Year. Month. Month. 1918 1919 1920 1918 1919 1920

January ...... 13.3 19.1 10.5 July.. 10.1 9.2 8.4 rF e ...... 2.6 17.7 16.0 August.10.1 8.3 8.4 March . 14.3 15.7 15.8 September .9.6 8.47.9 April ...... 1. 11.2 11.5 obr Oc ...... 18.2 8.2 ..... Mari..14.4 13.2 11.1 Ooveber .1...... 18.2 8.26 June . 10.5 9.8 9.8 December. 22.4 9.1 No.vember 12, 1920. 2718 PUBLIC HEALTH ENGINEERING ABSTRACTS. Report of the Department of Health and Sanitation of the U. S. Shipping Board for the period November 16, 1917, to November 15, 1918.-Licut. Col. Philipl Schleuyler Doane, M. C., U. S. A.-The Military Surgeon, vol. 47, No. 4, October, 1920, p). 389-406. The functions of the Department of Health and Sanitation of the Shipping Board included such measures as were found niecessary to gL ern sanitary, conditions for the shipworkers in the yards as well as in their living and eating places and7 to provide dispensaries and hospi- tals and medical and sanitary supervision cowering all shipyards in the country. In every yard, supervision was necessary in the matter of water supjly, housing, drainage, sewage -disposal, and general sanitary environment. In the water supply specifications issued to the yards, the department insisted that surface water from streams and lakes should never be used without purification; wherever possible the yards should use a water supply of established purity in a near-by city; shallow wells should be used only when absolutely free from soilWor surface contamination; walls of the well should extend above the surface with a provision for drainage that would carry surface water away from the well; bacteriological and chemical analyses shouGld be made at regular intervals by reputable laboratories, copies being sent to the Emergency Fleet Corporation. Not only the source but also the distribution of the water called for close watch- ing. One of the difficulties frequently encountered was the interconnection between the water mains carrying drinking water and those eonveying impure water for industrial use and for fire protection. Where such interconnection was absolutely necessary and was ac- qepted by the Department of Health and Sanitation and the local health authorities, an improved type of connection, consisting of two check valves, three pressure gauges, and two blow-offs, was specified, and monthly examinations were made to test th.-.tightness of these check valves. The war against the disease-carrying mosquito involved expenditures of $800,000, practically all being contributed by various outside organizations. The effectiveness of the department's work is shown by the fact that in no case has a general cessation of work due to disease occurred in any of the yards, and there was no epidemic of typhoid, smallpox, or other virulent disease, with 'the exception of influenza. Sanitary conditions in Vladivostok.-Ijieut. A. S. Judy, M. C., U. S. N.-Medical Bulletin, vol. 14, No. 4, October, 1920, p. 9. The population of Vladivostok was 60,000 before the war, and has increased to about 400,000, owing to the presence of refugees and 2719 November 12, 1920. allied troops. Conditions are most conducive to the spread of disease. An epidemic, such as cholera, would be difficult to arrest. The - ignorant defecate and urinate on almost any street at any hour, the material remaining until washed away by melting snow or ramsn. Water is obtained from wells, both public and private. In November, 1919, 70 cases of typhoid were traced to a polluted well water. Only 10 per cent of the city is sewered. Typhus fever is endemic, several thousand cases occurring in 1920. Four hundred cases of choleri occurred in 1919. Food is handled and prepared under very insanitary conditions. The farm woman tells her own story.-Florence E. Ward- Domestic Engineering, vol. 93, No. 4, October 23, 1920, p. 161. The United States Department of Agriculture made a survey recently of 10,000 farm houses regarding sanitary conditions, with results as shown in the following table.

Without running water (necessary to carry). With PowerWaeInSnadOuor Section of country. rnning macbhin, kitchen. Sand toilet Bathtub. r=1<. water. 1 ery. 1 1L1 Prcn.Distance ~~ktchn. mi. tIe.

Feel. Pcr cent. Per cent. Per cent. Pr cent. Per cent Per cent. Etern ...... 54 23 39 12 67 80 87 21 Central ...... 68 41 24 29 47 52 93 i8 Western ...... 57 65 36 22 18 44 86 23

Average ...... 61 39 32 22 48 60 90 20 Number of records... 6,511 6,708 9,320 9,080 6,949 9,334 9,580 6 784 Septic tanks for unsewered districts.-C. Edward Keefer, Engineer, Highways Department, Baltimore, Md. -Public Works, vol. 49, No. 17, October 23, 1920, p. 388. In view of the annexation by the city of Baltimore in 1919 of about 60 square miles, a considerable area of which was unsewered, it has been found advisable to install temporary septic tanks treating the sewage from various districts in this area. Septic-tank installations were decided upon in view (1) of the greater supervision required for Imhoff tanks, which are often erratic in operation; (2) the removal of sludge by carts, thereby eliminating one of the chief advantages for Imhoff tanks; and (3) the greater cost of Imhoff tank instaUations. The design of the larger septic tanks is based on a minimum -flow of 80 gallons per capita per day, a detention period of 8 hours with a foot of sludge in the shallower end of the tank, assuming an operating period of 18 out of 24 hours. Studies on the corrosive action of chlorine-treated water.-George L. Clark and R. B. Iseley, Vanderbilt University, Nashville, Tenn. Journal of Industrial and Engineering Chemistry, vol. 12, No. 11, November, 1920, pp. 1116-1122. November 12, 1920. 2720 This paper, as a preliminary to more practical work on the corrosive action upon living organisms and upon metal containers and pipes, discusses (a) the solution of chlorine in water under (1) methods of analysis; (2) equilibrium in the system; (3) effect of iron on equilibrium; (4) interpretation of results; and (b) corrosion of iron and steel, under (1) nature and extent; (2) interpretatioin; (3) secondary effects. Tests Were made with low-carbon steel bars of similar composition immersed in solutions of Cumberlapd River water, city reservoir- water, which is simply the river water treated with alum in settling tanks, and distilled water. The results showed that the owrosive action is greater in the light than in the dark, owing to the greater completeness of reactions involving the decomposition of HOCI in light to form HCI and oxygen. It was also found that corrosion usually increased-with increase in chlorine content in the order: river, reservoir, distilled water. DEATHS DURING WEEK ENDED OCT. 30, 1920. fIa the "Weekly Health Index," NO1. 2,1920, issned by-the Bureau of the Census, Department of Commerce.] D*ath from all causes in certain large cities of the United States during the week ended Oct. 30 1920, infant mortality (per cent), annual death rate, and comparison uith cor- retpon;ing week ofpreceding years.

Week enIded Oct. Per cent of deaths 30,1920. under 1 year. Population Average City. subject to death rate Week i revision. Total Death per 1,000.2 ended Prev ous 1920.

-Aon Ohio...... 20,435 28 7.0 3 8.9 17.9 315.9 Al , N. Y ...... 113,344 25 1 1.5 C 13.0 24.0 C 3.6 Atlnta, (a ...... 200,616I .59 15.3 C 13.4 16.9 C 3.9 Jlatimore, Md.. 733,826 194 13.8 A149 10.0 A 17.0 Birmingham Ala.178,270 45 13.2 A 17.9 15.6 A 12.9 Boston, Niass...... 747,923 193 13.5 A 15.6 16.1 A 17.8 Bridgeport,Conn ...... 143,152 34 12.4 A 13.4 35.3 A 20.4 Buffalo, N. Y ...... 506,775 137 14.1 C 11.4 19.7 C20.9 Cambrid&e Mass...... 109,456 27 12.9 A 13.6 14.8 A 13.0 Chicago, I...... 11 , 2,701,706, 498 9.6 A 12.2 17.7 A 15.9 Cincinnati,Ohio ...... 401,247 87 11.3 C 11.6 9.2 C 7.9 Cleveland, Ohio ...... 796,836 160 10.5 C 9.6 20.6 C 22.9 Columbus, Ohio .237,031 52 11.4 C 10.7 19.2 C 10.4 Dallas, Tes.158,976 26 8.5 A 13.0 19.2 A 14.3 Dayton, Ohio ...... 1583,830 22 7.5 C 11.7 9.1 C14.7 Denmer,Colo ...... 256,491 72 14.6 A 13.2 1.1 ...... Detroit, Mhch...... 9. . 993,739 166 8.7 ...... 28.3 ...... Fall River, Mass ...... 120,485 31 13.4 C 11.7 32.3 C 37.0 Grand Rapids,Mich ...... 137,634 28 10.6 C 13.4 25.0 C 17.1 Hartford, Ccnn...... 138,036 29 11.0 ...... 6.9 ...... Indianapolis Ind .314,194 76 12.6 C 11.9 15.8 C 11.3 Jersey city, R. J . . 29s 079 77 13.5 C 13.5 24.7 C 15.6 KansasCity, Kans...... 101,177 21 10.8 ...... 19.0 ...... KansasCity,Mo...... 324,410 85 13.7 C 15.3 12.9 C19.1 LcsAn eles,Calif ...... 576,673 144 13.0 A 11.3 .10.4 A 10.5 Lowell ...... 112,479 30 13.9 A 17.1 43.3 A 19.7 Memphs,Tenn ...... 162,351 66 21.2 C 18.5 7.6 C15.1 Miiwaukee Wis ...... 457,147 86 9.8 AI10 7 23.3 A 19.1 MfineapolZ minn .... 380,582 65 8.9 C 9.6 13.8 C 7.2 Nashville ienn. 118,342 44 19.4 C 13.3 20.5 C 13.3 Newarr, .J.... 414,216 76 9.6 C10.4 18.4 C19.5 New lBedford, Mass.121,217 29 12.5 A15.2 24.1 A30.4 New Haven, Conn.... 162,519 25 8.0 C 14.6 16.0 C13.3 IAnnual rates per 1,000population 2"A" indicates data forthe corresponding week of the years 1913 to 1917, inclusive. "C" indicates data for corresponding week of the year 1919. t!,Data are based on statistics of 1915, 1916, and 1917 2721 November 12, 1920. Deaths from all causes in certain large cities of the United States during the week en&d Oct. 30. 1920, itnfant mortality (per cent), annual death rae, and comparison with cor- tesponding week of preceding year-Continued.

Week ended Oct. Per cent of deaths 30, 1920. under I year. Population Average City. Jan.subject,1920,to - deathannualrate Week revision. Total Death per 1,000. ended deaths. rate. Oct.30 yr or

New Orleans La .387,219 114 15.4 A'21.3 19.3 A10.7 New York'.Y 10.0 0 9.8 15.2 C 15.7 Norfolk Va...... 5,620,048115,777 1,08223 10.4 ...... 17.4 OaklanA Calif .216,361 46 11.1 A 10.4 4.3 AIS.3 Omaha, Wbr. 191,601 36 9.5 011.0 2D.0 020.Q Philelphis Pa. 1,823,158 413 11.8 814.1 16.9 s14. Pittsbu a . .588,193 157 13.9 013.5 10.2 C 21.1 Portlnd,6reg ...... 258,288 58 11.3 0)2.8 10.7 0 7.9 Providence, R. I .237,595 81 13.4 C 15.6 14.8 CG127 Richmond, Va . 17167 38 11.5 014 a18.4 020.0 Rochester,N. Y .295,750 78 13.8 a 9.1 10.3 0 11.8 St.LoisMo..772,897 175 11.8 010.3 14.9 C 7.9 St. Paul, Mn. . 234,680 28 6.2 012.5 .7.1 - 0 8.9 Salt Lake Cit, Utah .118,110 29 12.8 A 10.8 13.8 ...... San Franesco, Calif ...... 506,676 110 11.3 011.4 8.2 B.4 Seattle, W.... 315,652 63 10.4 A 8.6 - 6.3 A 12.1 Spokane, Wash .104,204 21 10.5 C10.0 28.6 C 5.0 Spr;,:ueldd Mass. 129,338 23 9.4 ...... 21.7 STraluse, 6.171,647 39 11.8 G15.3 15.4 010.0 Toledo, Ohio ... T...... 67243,164 12.2 A14.5 15.8 A .8f Trenton, N. J .119,289 39 17.0 A 15.3 12.8 A I. Washington, D. 4..37,571 100 11.9 A1-5.6 17.0 A13.8 Wilnranton,Del . .110,168 22 10.4 0.12.9 18& ...... Worcester Ma...... ss 179,754 36 10.4 C6.7 22.2 C 4.3 Yonkers, N.Y . .100 176 18 9.4J Al2.6 22.2 A17.1 Youptown, Ohio ...... 132,358 34 18A...... 23.5 .

3 Dat3 are based on statistics of 1915, 1916, and 1917. Summary of information received by telegraph from industrial insurance companies for week ended Oct. 30, 1920.

Policies in force ...... 44,726,4t79 Niumber of (leatli claims...... 8.... 6, 89 Death claina per 1,000 policies in force, annual rate. 8 15J"1020-2 PREVALENCE OF DISEASE.

No healh departmen, State or local, can efectively prevent or control disease without Znowlcdge ofwhen, there, and under what conditions cases are occurring.

UNITED STATES. /

CURRENT STATE SUMMARIES. Telegrapldc Repots ror Week Ended Nov. 6, 192E)

These reports are preliminary and the Sigres are subject to cban when late retums are reoived ty te State hetb offler ARKANSAS. CONNECUuT-ctn ued. Ces. Os amtie...... 1 Geruman meases...... 2 .

Cicken p Ox ...... 4 Influenza.. 15 t)iphther...... 58 Meses: . Bokworm...... 1 Pomfret . 9 Infi a..... * 40 Putnam (town) ...... 44 .alar.a. .. 147 Putnam (city) ...... 6 .

le ...... 54 'Tompson. .8 Pellam ...... ,.... 7 Scattering .9

Scarlet fever ...... 39 Mumps 12

.4 ...... 4 Pneumonia (lobar) ...... 9 Trachoma...... : ..5 Pollomyelitis...... 7 Tuberlosis ...... Sclet fever. Typhoid fever ...... 31 Bridgeport ...... 8...... 8 Wbeopig cou ...... 36 Hartford ...... 8 New Haven. 9 cAWoEnA. Scattering. 49 4 Tuberculosis (all forms) .32 Cerebro6pinal meningitis...... Typhoid fever .14 Iuenza...... 13 Poliomyelitis-Los Angeles...... 1 Whooping cough. 52 smallpox: DELAWARE.1 8 Arroyo Grande...... Chicken po ... 2 . 13 Escondido...... Cholera infantum .. 1 Woodland...... 17 Diphtheria: 50 Scattering...... Wilmington . . . 12 29 Typhoid fever...... Scattering ... 2 CONNECTICUT. Measles ... 2 1'neumonia . . . 2 Cerebrospinal meningitis ...... 1 Scarlet fever .. . 13 Chicken pox...... 5 Tuberculosis . . . 17 Diphtheria: Typhoid fever.... 9 Bridgeport ...... 11 Whooping cough .. . 12 Greenwich ...... 15 FLORIDA. Hartlord ...... 32 New Britain .. 11 Diphtiheria ...... 18

New Haven ...... 13 Influenza...... 7 Waterbury . . 9 Leprosy...... 1 Scattering ...... ; 45 Malaria...... 16 Dysentery (bacillary) ...... 1 Pneumonia...... 2 ' Two weeks. (2722) '2723 November 12, 1920.

FLORIDA-continued. Cases. IOWA. Cas.

Scarlet fever .. 6 Diphtheria ...... 52 Smallpox ... 9 Influenza ...... I Typhoid Poliomyelitis-Cresco ...... I

Scarlet fever ...... GEORGIA. Smallpox:

Ottumwa...... ; 24 Chicken pox ...... 10

...... 56 Coijunctivitis (acute Infectious) ...... Scattering Dengue...... 19 Tubercu osis (pmonry) ...... I Typhoid fever ...... 8 Diphtheria ...... 61 Dysentery (amebic) ...... 12 KANSAS. Dysentery (baciUary) ...... 4 meningitis ...... 3 Hookworm ...... 21 Cerebrospin3l

Chicken pox ...... 13 Influenza ...... 44

...... 265 Malaria ...... 105 Diphtheria Dysentery (amebic) ...... I Measles .... . 2

Influenza ...... 3 .....,,, 2 Measles 60 Paratyphold fever ...... 4 ...... Pneumonia.... 19 MumPS...... 4 . 3

Pneumonia ...... 12 Poliomyelitis ...... 2

Scarlet fever ...... 220 Scarlet fever ...... 23

...... 837 S6ptlc sore throat ...... 10 SmallpQx Tuberculosis ...... 50 Smallpox ...... : 7 fever ...... 31 Trachoma ...... 1 Typhoid

Whooping cough ...... 42 Tuberculosis (all forms) ...... 17 Typhold fever ...... 17 LOUISIANA, Whooping cough ...... 23 Cerettospinalmeningitis.... ILINOIS Diphtheria ...... 18

Cerebrospinal meningitis ...... 5 Infltrenza...... 32

Diphtlferia: Scarlet fever ...... _.',15

Chicago ...... 305 SmAllprox ...... ;... 8

Evwnston ...... 12 MAINE. 83attering ...... 93 Influenza- Cerebrospinl meningitis ......

Chicaga ...... 0 Chicken pox ...... 16 I Scattering ...... Diphtheria ...... 38

Pneumania-Chicaga ...... 88 Influenza ...... 3

Pollomyelitis: Mfeasles ...... 47 5 Chicago ...... Mumps...... 2

Elgin ...... , Pneumonia ...... 5

Evanton ...... Poliomyelitis-Bar Harbor ...... I Gabsburg ...... Scarlet fever ...... 15

Lemont ...... Tubercu!osis ...... 5

McLean ...... Typhoid fever ...... 17

Oak Park .....1...... I Whooping cough...... 11 Sangaman County-Voodside Township.. I Scarlet fever: MARYLAN'D.1 Chicken pox...... 20 Chicago 150 Dipbtheria ...... 71 Oakford 8 Dysentery ...... 11 Springfield ..8...... Influenza ...... 9 Scattering 71 Smallpox: Measles ...... 14 Mumps...... I Augtsta ...... 9 Ophthalmia neonatorum ...... I Scattering ...... 16 Pneumonia 27 Typhoid fever: (all forms) ...... Scarlet fever ...... 35 Chicago ...... 12 Tuberculosis ...... 46 Scatterinf ...... 22 Typhoid fever ...... 23 INDIANA. WVhooping cough ...... 44 Cerebrospinal m.iingitis-Mforgan County. MA5sscA UsMS. Diphtheria ...... 125 Scarlet fever ...... 7 Cerebrospinal meningitis ...... 3

Smallpox ...... 95 Chicken pox ...... 119

Typhoid fever ...... 57 Conjunctivitis (suppurative) ...... It I Woek ended Friday. November 1,2 1920. 2724

mAsScCu aHTts-.continued. Cases.

- 204 Diphtheria ...... (Exclusive of Now YorklcCity.) Case&

German measles ...... - 4 Cerebrospinal meningitis-Colonle ...... 1 Influenza ...... 18 Diphtheria ...... 359 Malaria ...2,,,,,..;...... ,., 2 Influenza ...... 30

Measles ...... 394 Lethargic encephaUtis ...... 1

...... 22 mumps Measles ...... 463

Ophthalmia neonatorum .. 18 Pneumonia ...... 110

Pneumonia (lobar) .. 40 Poliomyelitis-Big Flats ...... 23 Poliomyelitis .. Scarlet fever ...... 159

Scarlet fever .. 138 Smallpox .....9

sore throat .. 3 Septlc Typhoid fever ...... 43 3 Tracboma.... Whooping cough ...... 262 Tuberculosis (allforms) ...... 148 NORTH CAROLIN. Typhoid fever ...... 22 Chicken pox ...... 23 Whooping cough ...... 76 Diphtheria ...... 172

* - E0MINSOTA. German measles ...... 3 Poliomyelitis ...... Measles ...... 36 17 Smallpox ...... Scarlet fever ...... 68

Septic sore throat ...... 7

...... Diphtheria ...... 62 smallpo IS Scarlet fever...... 30 Typhoid fever ...... 28 Whooping cough ...... 165 Smallpox...... 4 Typhoid fever...... i6 OHIO. MONTANA. SmalIpoX-Lima ...... 79 Diphtheria...... 2 Typhoid fever-Salem, opidemic. Po}iomyelitis: SOUTH DAKOTA...... Grantsdale Chicken 7 Hobson...... pox Diphtheria ...... 1....i5 S bey...... 2 Measles ...... 34 Scarlet fever...... 20 Pneumonia ...... I Smallpox...... 10 Scarlet fever ...... 14 fever...... 7 Typhoid Smallpox 7

NEBRASKA. Typhoid fever ...... 6

Whooping cough ...... -. 3 Cerebrospinal meningitis-Omaha......

Chicken ...... '14 TEXAS. Diphtheria: Diphtheria ...... 143

Malaria ...... 51 MIeCook ...... ; 8 Omaha .12 Scarlet fever ...... : 13 Scatteing .24 Typhoid fever ...... 8 Measles8 VERMONT. 1 Polomyelitis-0smond. Chicken pox ...... 40 Sarlet fever .21 17 Smallpox: Diphtheria ...... Measles ...... 7 Neligh. 8 Mumps ...... 18 Scattering ...... 26 Pneumonia ...... 3 Tuberculosis 1 Scarlet fever ...... 13 Typhoid fever .11 Smallpox ...... 8 Whooping cough. 4 Typhoid fever ...... 5

NEW JEREY Whooping cough ...... 9 16 Influenza ...... WAHIMNGTON. Pneumona .64 Chicken pox ...... 44

:NEW MEXICO. Diphtheria ...... 44 Chicken pox...... 3 German measles ...... 1

Influenza ...... 4 Diphtheria ...... 31 Ma.a...... 2 Measles ...... 15 Measles...... 9 Mumps...... 4 Mumps...... 2 Pneumonia ...... 1

Pneumoni ...... 1 Scarlet fever ...... - 23

Scarlet fever ...... 9 Smallpox ...... 59 Tuberculosis ...... 69 Tuberculosis ...... 5

Typhoid fever...... 3 Typhoid fvcr ...... 10 Whooping cough...... 32 Whooping cough ...... 6 2725 November 12,41920. _

WEST VIGIA. wicossm-continued. Diphtheria: Cases. Milwaukee-Continued. Cses Blueeld...... 10 Smallpox ...... i 13 Scattering...... 33 Tuberculosis .13 Measles...... 8 Whooping cough ...... 13.....13 Scarlet fever...... 20 Scattering: Smallpox: Cirebrospinal meningitis I Clarksburg...... 8 Cbicken pox .54 Sistersville...... 8 Diphtheria .92 Typhoid fever...... 1 Influenza .12 WISCONSIN. Measles .75 Milwaukee: Poliomyelitis 4 Cerebrospinal meningitis...... 1 Rubella 3 Chicken pox...... 7 Scalet fever .111 Diphtheria...... 64 Smallpox. ; 69 Influenza...... 1 Tuberculosis .18 Measles...... 6 Typhoid fever 9 Scarlet fever...... 22 Whooping cough .113 Kentucky Report for Week Ended Oct. 30, 1920. Ca,Ws. Cases. Chicken pox...... 8 Poliomyelitis-Barren County...... I

Diphtheria: Scabies ...... - 2 Graves County...... 10 Scarlet fever:

Lincoln County...... 16 Lincoln County...... 9

Logan Cotnty...... 8 Scattering ...... 35 McCracken County...... 9 Septic sore throat ...... : 2 Scattering...... 56 Smallpox: Dysentery ...... 11 Logan County...... 9

German measles ...... 2 Scattering ...... -.. . 22

Influenza...... 10 TonsilUtis ...... 4 Measles...... 3 Trachoma ...... 2

Membranous croup ...... 2 Tuberculosis ...... 12

Mumps...... 4 Typhoid fever ...... 33 Paratyphoid fever...... 2 Whooping cough...... 23 Pneumonia...... 23, SUMMARY OF CASES REPORTED MONTHLY BY STATES. Tables showing by counties the reported cases of cerebrospinal meningitis, influena, malaria, pellagra, pollomyelitis, smallpox, and tyhold fever are published under the names of these diseases. (&ee names of these and other diseases inUhie table of oontents.) The folowing monthly State reports include only those which were received during the current week. These reports appear each wee as received.

State. V V

1920. Connecticut (September) ...... 3 190 16 3 66 8 130 1...... L Delaware (August) ...... 1 8 ...... 16 1 8 Delaware (September) . . 9..... 12 .... 14 Ihawaii (.September) ...... i1 6 12 29 ...... o. Iowa (September)...... 1 87 ...... 7 141 11) ...... Kansas(September) ...... 2 388 14 11 57 2 B 324 91 221- Ohio (September).9 707 44 4 122 13 538 141 494 Virginia (Septembe) .9 411 ...... SW 5151 21 7 128 109 359 XIovember 12, 1920. 2726 - RECIPROCAL NOTIFICATION. Connecticut, October, 1920. Cases of ctmmuniable diseaes refer7e4 -during October, 1920, to other State health departments by department ofhelth of the State of Connecticut.

Diseases and locality of Referred tohealth |Vhyreferrd. notification, authority of-Whrered lleasles: Pomfret, Cann...... State Department of Public Four children expsed to a case of measles while Health, Boston, Mass. in Snrin ficid, Mas. becameil on returnhome to Iaomfret, Conn. Bearlet fever: New London,Conn.. State DepartmcntofHealtb, Onset of disase three days after leaving New Albany, N. Y...... York City. Tuberculosis: Hartford, Conn...... State Board ofHealth, Con- Patient, now ill with tuberculosis in Hartford cord N. H. Conn., residentof Manchester, N. H. Typhoid fever: Farfield,Conn. State Department ofHealtb, Onset ofdisease less than two weeks afterleaving Albanv, N. Y. Port Jefferson, N. Y. Danielso, Conn. State lBoard of Health, Onset of disease in Quanintaug, R. I.,, patient Providence, R. I. returning homeill to Danielson, Conn. nsonla, Conn....S.State DepaWtment of Public Onset ofcase 14 days after leavingChesirElMass. Health, Boston, Mas. erlin,Conn .....do .Patient visited in Northampton, Mass, while inincubationperiod ofdisease.

ANTHRAL Lae, Idaho, and ouweil, Mass Under date of October 27, 1920, one case of anthrax was reported at Lane, Idaho. During the week ended October 23, one death was reported at Lowell, Mass. CEREBROSPINAL MNNGITIS. State Reports hor September, 1920.

Plnee. | reported.

Connecticut: Ohio: FiLaield County- Allen County. Danbury I Cuvahoga County ...... , 1 Hartf ,rd County- Jeers )n Cuntyn. I artford. . 1. Hamilton County .1 New London County- Montgomery Cunty. 2 Lonudon .1 Shelby County . I NW Summit County. 2 Total ...... _ - Total o t a l 9 Iowa: - Iowa County ...... 1 Virginia. Alexandria County- Kansas: Alexandria .. Montgomery County- Alleghany County. 06ff1 p-ilie.1 Bland County . Baline County- Henrico County. a Salina ...... 1 Richmond. I I :Henry County. I Total ...... 2 Nottoway County. Total. 9 -2727 November 12, 1920. CEREBROSPINAL MENINGMS-Coutinued. City Reports for Week Ended. Oct 23, 1920. Thecolmnnhe3ded "Average cases' givesthe average number ofcases reported during the corresponding week of the years 1915 to 1919, iniluive. In instances in which thke information is not available for the full five years. the average includes from one to four years.

Aver- 1920 Aver- 1920 Place. age Place. age caes Cas. Deaths. csCases. Deaths. California: lMichigan: 1.o Angeles ...... 0 1 Detroit...... 2 . 1 Pasadena ...... 0 1 ...... New Jersey: S1anFrancisco ...... 1 1 Newark...... () 1 1 Connectictut: Trenton (i)... 1) I Hartferd.(.) 1... New York: District of Columbia: New York...... 3 2 . Washington ...... (1) 1 .. Ohio: Georia: Dayton.() ...... Atlanta .0 1 ...... Oregon: Illinis: Salem ..2...... 2 Chicago ...... 3 1 Pennsylvania: lndiana 1 - lliladclphia .1 ...... II..1.1. Muncie.... , ...... 1O...... Virginia: Maine: - Portsmouth...... 0 .... I Bangor . . 1 ...... Wisconsin: -Massahusetts: Greet: Bay ...... 0 1 I Methuenl...... O 1 1 Milwatukee ...... i2 . 2 0 1 ...... I alcm . Waiusau 'Average loss than 1. DENGUE. Savannah, Ga.-Week Ended Oct. 23, 1920. During the week ended October 23, 1920, 39 cases of dengue, with two deaths, were reported at Savannah, Ga. DIPHTHERIA. See Telegraphic weekly reports from States, p. 2722; Monthly sumniaries by States, p. 2725; and Weekly reports from Cities, p. 2742. INFUENZA. Ohio Report for September, 1920.

New e &e Place.~ ~ reported. casesoPae reported. Ashland County ...... 7 Hamilton County...... I Belmont County ...... 7 Lawrence County...... 19 Butler County ...... 1 Licking County...... 3 Cuyaboga County ...... 3 Wa3hington County...... Fayette County...... 1 .... I Franklin County...... 1.... . I Total.. U November 12, 120. 2728 INFLUENZA-pontinued. City Reports for Week Ended Oct. 23, 1920.

Place. Cass. Deaths. Place. Cases. Death. California: Michigan: Long Beach ...... 1 ...... flighland Park ...... I Los Angees. . 2 ...... Minnesota: Oakland...... 1 .- Minneapolis ...... 1...... Riverside...... 2...... Missouri: Colorado: KKansas City. 2 . Denver ...... 2 St. 1. ouis ...... 6...8. Connecticut: New Jersey: Bridgeport.2...... Newark...... 4 District of Columbia: ...... Trenton. W .ashington .. 3...... New York: Ceergiao Jamestown ...... , .-.1. Atlwnta ...... 4 Mount Vernon.I...... Bannswick . . 7 . . New York...... 14 5 Rome...... 3 ...... North Tona*anda...... 1 Illmois: Saratoga Springs ...... 8 Chicago ...... 16 1 Ohio: Danville ...... 1 ...... Ashtabula...... 2 . Kentucky: Cleveland.. Lexington...... 1 ...... Pennsyvlvania: Maine: Philadelphia .3 I Portland ..1 Texas: Maryland: Dallas ...... 2 . Baltimore ...... '.... 11 I Vermgnt: Cumberland...... 1.... 4 ...... Ve-utiand...... I MBoMehlsetts: Virginia: Boston ...... Z ...... ~Lynchburg...... b Fall River ...... 2 Lynn...... I......

LETHARGIC ENCEPHAITIS. Connecticut-September, 1920. During September, 1920, three cases of lethargic encephalitis were reported in Connecticut. MALARIA. State Repots for August and September, 1920.

IPlNace. |[ewreported.cases Place.Pa.ewocaesNewcasp s

Connecticut (September): Ohio (September): Fairfeld County- Butler County...... I Greenwich . 2 Licking County...... 1 Hwtford County- Montgmery County...... 1 Hartford. 1 Richland County...... 1 Total. 3 Total...... 4 Delaware (August): Virginia (September): Kent Count- Accomac Colnty...... as Harrington (town). 1 Chincoteague...... 7 New Church...... 8 Kanss (Septemb.er): Alexandria County- Cherokee ounty- A lexandria...... 1 Columbus . 3 Amelia County...... 3 Montgomery County- Augusta County- Indepenene.c 2 Waynesboro...... 1 Shawnee County- Bath CotuitY...... 1 Topeka. 1 Bedford County...... 3 S3umner County- Brunswick County...... 23 Conway Springs. 2 Lawrenceville...... 2 Wyandotte County- Campbell C'ounty...... 2 Kansas City. 3 AItavista...... 2 CaroHne County...... 10 Total 11 Charles City County...... 8 Chesterfield County...... 15 2729 *Novembet 12, 1920. MALARIA-Continued. State Reports foir August and September, 1920-Continued.

rlace. Newlreported.cases Place. - NewearLesreported.

Virgina (September)-Continued. Vir i i (Septembyr)-Continued. Cumberland County ...... 5 TAfoXCounty- Dinlwiddle County ...... I Portsmouth. 4 Elizabeth City County- Northampton Couny49 Phoebus ...... 6 Cape Charles ...... 16 Essex County 2 .. . 2 Northumberland County. 9 Fauouter County- Nottoway County- Remington ...... 1 Crewe...... 1 Greensville County ...... 14 Pittsylvania County .. 19. Emporia .27 .Powhatan County.. 8 Halifax County ...... 2 Prineess P nne County . , 46 South Boston . .11 Prince Edward County- Hanover County ...... 12 Farmville 1 Henrico County...... 32 Prince George-ounty.1 Richmond 2.. . 2 Ri hmond County. 3 Tsle of Wight County ...... 17 Roanoke County- James City County ...... 10 .alem.. . 2 Williamburg 3...... 3a Rockbridge County...... 2 King and Queen County . . 29 Lexington...... 2 King William County ...... I Southampton County...... 8 Lancaster County- Spotsylvania County. 2 . Irvington... . 4 Stafford County . . 2 Louisa County.. 2 Surry County .18 Lunenburg County. 2 Sussex County .18 Kenbridge . .1..Stony Creek.. 2 Mathews County 2.. . 2 Warwick County .. 20 Mecklenburg County.. .14 Westmoreland County .. 4 Middlesex County IS.. . 15 Wise County- Nansemond County a.. 2 Norton . Stuffolk...... 10 York County. 6 Nelson County . . I New Kent County .. 4 Total .595

City Reports for Week Ended Oct. 23, 1920.

Place. J Case. Deaths . Cases. Deaths.

Alabama: Massachusetts: Birmingham ...... 1 Arkansas: - Lawrence ...... 1 Hot Springs ...... 5 1 New Jersey: LittleRock ...... 9 ...... EastOrange...... 1...... Califomia: Ohio: Long eachl ...... 1 ...... Norwood...... 1 Los Angeles ...... Oklahoma: Georgia: Oklahoma City ...... 1 Atlanta...... 3. .. Pennsylvania: Brunswick...... 10 ...... Philadelpbia ...... 1. .. Macon ...... Carolina:...... South.....1 Rome...... 4 ...... Charleston...... 1...... 1 Savannah ...... 3 ...... Columbia...... 1. Illinois: Tennessee: Danville ...... Memphis...... 2 Louisiana: Texas: Alexandria . . . 15 ...... Dallas...... 423 Virginia: Portsmouth 1

MEASLES. ,ee Telegraphic weekly reports from St-ates, p. 2722; Monthly summaries by States, p. 2725; vnd Weekly reports from cities, p. 27-12. November 12, 1920. 2730 - PELLAGRA. Kansas and Virginia Reports for September, 1920.

Place. Newcass Place. Nowr ated

Kansas: Virginia-continued. Cowley County- Henry County- lVinfleld ....J..,...... I Martinsville*-***...... 2 Douglas County- James City County- Lawrence 1.... 1 Willamsburg .1 Norfolk County- Total . .2 Norfolk...... I - Scott...... County . Virginia: Southampton County 10 Acoomac County ...... 1 Washington County. I Bland County...... 1...... 1 Brunswick County ...... 2 Total...... 21 Elizabeth City County .1

City Reports for Week Ended Oct. 23, 1920.

Plae. Cases. Deaths. Place. Cases. Deaths.

Alabama: Massachusetts: Montgomery ...... 1 Beverly...... 1 Georgia: Worcester .1 -. 1 Atlanta ...... 1 New York: KIentucky: New York ...... Lekxington...... 1..... North Carolina: Louisiana: WinstonSalem .. .. I Alexandr.a.1...... South Carolina: Charleston ...... I

PLAGUE. Human Cases of Plague Reported.

Place. ' Period covered. Cases. . Deaths. Remarks.

Florida: 1920. Pensacola ..... May31 toAug.31...... 104 Sept. I to Nov. 6 .0 0 Lotisiana: 1919. New Orleans .Oct. 22 to Dec. 31.12 4

Jan. ItoApr.30... O 0 May 1 to Aug.31.. 7 3 Texas: . Sept. Ito Nov. 6 . . 0 0 Beaumont...... June 19 to Aug. 20 ...... 14 5 Aug.21 toNov, 6 ...... 0 0 Galveston .June 8 to Oct. 20 ...... 16 10 Oct. 21 toNov. 6 .0 0 Port Arthur ...... July 7..1 * 1 ...... 1 From Galveston. 2731 November 1Z, 1920. PLAGUE-Continued. Pgwue-infected Rodents.

Rodents. plac Period covered. plaguefound infected.

Florida: 1920. Pe nsasola. June28to Sept. 19 . 31 Sept.20toNov. 6 ... 0 1919. touislana: New Orleans'.. . November ,102. December .. ; 206 1920. J*l ...ar...... 148 February . .66 March ..25 April ...... 11 May .. 7 June . . 4 July . .... - 2 August . .0- September...... 2 October...... 1 Nov. 1-...... 0 ¶hxas: 12 Beaumont ..... July lto Sept. 19 ...... 122. Sept. 20 to Oct. 24 . .0 Oct.25 .. 1 Oct.26 to Nov. 6 ...... *...... 0 Galveston .Jun 21 to Oct.29 ;0. . Oct. 22to270....-. - . ; . . 0 Oct. 30 to Nov.8. 0 Nov. 9..1 Prt Arthur...... Oct.,125 . .

ICorrected figures to date. 26 miles out on road to Port Arthur. PNEUMONIA (ALL FORMS). City Reports for Week Ended Oct. 23, 1920.

Plae Cases. Deaths. Place. Cases. Deaths I Alabama: Illinois: Bir inghar. 5 Bloomington...... , 2 - Mobile...... 1 Chi-ago . .... 19 Arkansas: East 'tt. Louis...... kot Sprins...... 1 Jackson-ile...... 2 ...... North Little Rock... Kewance...... Oak l'ark ...... 1 California: 1 Fresno...... Peoria...... I Long Beach...... 2 1 Rockford ...... 2 Los Angeles ...... 14 4 Rowk I-lsnd...... 2 ...... i Oa' land...... Springfield ...... Ri erside. 3 Indiana: Sacra: ento. 1 ...... k1 Ikhart ...... 1 San Diego...... 1 Gary...... 1 San Francisco -...... 3 Indianapolis...... 4 Santa Cruz...... I2 ...... La kavettc ...... 3 Colorado: 41 Mtincie...... 3 Pueblo...... 2 Rtichmond ...... 1 Connecticut: Kansas: Bridgeport ...... 5 Kansas City...... 2 Bristol...... Topel a .... . 1 Nex Britain...... Wlchita...... 3 Norw-ich ...... 1 Waterbury ...... 4 2 Kentucky: DistTiPt of Colhlmiia: Louisville...... 9 Washington...... 8 Louisiana: Georgia: New Orleans...... 8 Atlanta ...... 1 4 Maine: 1 RoLe.: ...... 1 ...... Biddeford ...... ''''''''.i Savannah ...... 3 Portland...... November 12, 1926: - 2732 PNEUMOMNA (ALL FORMS)-Gontinued. City Reports fi Week Ended Oct43, 1920-Continued.

Place. -Cass. Deaths. Place. J Cases. Deaths..

Maryland:' New Jersej-Continued. Baltimore ...... 20 7 I Plainfield...... Cumberland...... 3 Trnton...... 2 Massachusetts: West New York...... Attleboro...... 1 Now York: Boston. 13 19 Albany...... 6 ...... I Cambridge...... 1 Aubun...... 2 ...... Chelsea...... Buffalo...... 16 3 Easthampton.. 2 Cohoes'.- 3 Everett...... 2 Elmira...... '''''''''i' Fall River...... 2 2 Hudon 1 Haverhill...... 2 Ithaca...... 1 Holyoke...... 1 Jamestown...... 2 I Leomnlnster. Jackawaa...... 8 2 ...... Middletown . 1 ifaldemLM ...... Mount Vemon.. 6 New Bedford...... 3 New York. 169 -. I 'Newtoh.... 1 1 North Tonawanda. 2 North Adams...... Port Chester. 1 ...... Northampton...... Rochester . 8 .,I North Atileboro...... 1 Rome...... 1 Plymouth...... i Saratoga Springs. 1 Salem. 9 4- Soluerville. 1 3 Springfield...... 1 2 White Plains. Thaunton...... 2 Yonkers. 3 Watertown...... 1 North Carolina: Westfeld...... 1 1 Charlotte...... Worcester...... 5 5 Durham...... Michigan: Wilmington., ...... Ann Arbor...... 1 Ohio: BattleCreek...... IAkron. Detroit ...... 431 IAlliance.BAlrm...... Flint ...... 9. AiancenatBarberton.-...... ' 15 .81 Grand Rapids...... Cincinnati.: ...... 1 Highland fark...... 4 Clevbland...... I aamazoo...... 2 2 Dayton. 2 Pontiac...... 1 1 East Cleveldnd. 2 2 Minnesota: IMarIon . 1 Duluth...... Portsmouth...... Mneapolis...... 43 ISprngfield.. 3 2 ...... St. Paul...... TFollo...... Missouri: Cape Girardeau...... IOregj:oorl d ...... 4.1 Jelferson City...... 2 Pennsylivania: Kansas City...... 2 I Philadel his...... 73 3 St. Joseph...... 2 Rhode fs1an Montana: Craton...... 1 Billings...... 1 ...... Providence...... Butte...... South Carolina: Great Falls...... 2 Charleston: ...... 3 issoula...... 1 spartanburg...... Nebraska: Tennessee: Fremont...... 2 Nashville...... Lincoln...... 1 Texas: 2 Omaha...... 3 Dallas...... 2 Nevada: El Paso...... 3 Reno...... 2 Galveston...... New Hampshire: Houston...... Concord...... Utah: I Manchester...... Salt Lake City...... I Portsmouth...... 1 Virginia: 2 New Jersey: Danville...... Atlantic City ...... 3 2 Richmond...... 2 Bayonne...... 1 Staunton...... Bloomfield...... 1 West Virginia: Jersey City...... 3 Charleston ...... Rearny ...... I ...... Huntington...... 2 lMotclair...... 3 Wisconsin: 1 Ilorristown...... 2 Fond du Lac. Newark...... 28 M1lwaukee...... :::::: 14 Passaic...... 2 Wausau...... 1 Paterson ...... 2 - 27-33 November 12, 192k POUJOMYELITIS (INFANTIL PARALYSIS).7 State Report for September,, 192.

1'lace ~~~New castes repWrted. Plawe.Necu rpr" Connecticut: Kansas-Continued. Fairfield County- Lyron County- Bridgeport...... 1.....Emporia ...... 2 Hartford County- Hartford Total.3...... West Hartford...... 1.... Ohio: Litehifleld County- AsRhland County...... 1 Plymouth...... 1I Cuyaboga County ...... 3 New London Counaty- CTroton...... 3 HamiltonEreCut2CountY .2...... Windhiam CountTr- . 1 LuasCounty...... 2 Putnam...... - I Mngmr County .1...... Mercer County .1...... Total ...... Ottawa county. .1...... iowa: ~~~~~~~~~~~~~~WoodCounty .1...... Blacklawk County Tota...... 13 Boone County .1...... Virginia: C3erro Gordo County ...... 3 Cmbell County.1...... Dubuque County.I upprCounty .1...... *Webster County.1 Le Cunt...... Roank ouny Total...... 7 Rnk...... Russell County...... 2 Kansas: Tazoweil County;.1...... ButleriCounty- Benaton ..1...... Total.7....

Caty Reports for Week Ended Oct. 23, 1920. IThe colamn headed "eAverage casee" gives the average number ofcase reportedl during the correspond- hsgweek ofthe years1915 to 1l9,iLn'IsI.Ve. Ilninstancesin which theinformiationisuot available.f9rthe fuli five years,thc averageincludes froam one to four years.

1920. 1920 Place.~~age Place. age

Calfornia: Massachusetts-Continued. Long Beach ...... 0 1..... SomerAlle...... 1 I 1 LosAngelos .(.....). 1 Waltham ...... 2 3 .... Ilinois: Watertown.1.------Aurora....'...... 1..... Mchigan: 2 Gbem ...... 4 ..... Detroit.(I). I Ibdiana:Fln.....2 Richmond...1...... I..... Missouri: Mamae: St. Louis...... 0 1.... Bangor...... 1. New Jer3ey: Portland...... (1 1Ne-arkc...... 0 1. Massachusetts: Orange ...... 1.0 Boston...... 8 2 Rah ay ...... I..... Brockton .(....)... 3...... New York: Brookline.1...... 1 .... Middletown...... 0 1.... Cambridge...... 2 5 2 NewYork .'...... 2 12 . Chelsea ...... 0 1. Ohio: Danvers.1...... Cleveland ...... 2 1..... Dedham...... 0 2 ...... Pennsylvania: Everett ...... (1) 1 Erie...... (1) 1..... Haverhill ...... 0 1 Johnstown ...... 0 1..... Lawrence ...... 0 2 1 OilCity...... 0 1..... Lowvell.1...... 1 ..... Philadelphia ...... 20 1..... Lynn ...... 2 2 1 Uniontown.-----. ....0 1..... Medford...... (1) 1 .. Warren ...... 2..... Melrose. 0 1 ...: Rhode Island: North Attleb'oro...1---I .. PealWxy...... Wiscnsin:Ne-port;.0....1.... Salefli...... 1 Green Bay...... 1 1 ' Averageless than 1. 'EBicludng 1918 and 1917, epidemic years 'E.ihg1918, an epidemic year. Novemltr 12, 1920. 2734;

* RABES sIN ANIMALS; Kasas City, Mo., and Hutton, Te. During the week ended October 23, 1920, one case of rabies in animals was reported at Kansas City, Mo., and one case was reported at Houston',Tex.' JRABIES IN MAN. Lee County, S. C.-September, 1920. During September, 1920, one case of rabies in man was- reported in Lee County, S. C. SCARLET FEVER. SeeTelegraphic weekly reports from States, p. 2722; Monthly summaries by States, p. 2725; and Weekly reports from cities, p. 2742. SMALLroL H KRsa Report for September, 1920-accintation Histories.

Vaccination history of cases.

New Place. - cases Deaths.Dah. Vaccinatedwithin vaccnatedInast Never History reported. more than sucess not obh 7yas fully tained or P =preg cdingpe vaccinated. uncertain.

Kbisas: Barton4Contf - eat Bend...... 1 ...... , 1 ...... Bourbon Countyr- att. . a.. Fort Scott...... 1 Butler County- I.. nut...... - 4 ...... 1...... I El Dorado...... _. 2 ,Crawford County- Pittsburg. 1 ...... ,...... 2 Dickinson County- Chapman...... Hope...... Ellis County- Hays. ; 1 ...... Fainklin County- Ottawa...... - Harvey County- 1 Newton...... 1 ...... I JewellCounty- Randall...... I...... I Mankato...... Johnson County- ...... -Lezena...... 2 Kinsman County- 10 Kingman...... 2 Linn County- ...... I...... ,...... Pleasanton...... 1...... 2 Boicourt ...... MarshallCounty- ...... Marysville...... 2 ...... 1 ~ Montgomery County- 1 ...... ,,...... Coffeyville..;..... 10 MorrisCounty- ...... |...... Cotincil Gnrove...... 1 Neosbo County- - Urbana...... '...... 2 Ness County- NessCity. 2 Osage County- OsageeClty...... 10 ...... 2.....2...... 6 2 PMhlllipsCounty-' 1 ...... I 2735 November 12, 1l0. S"ALLPOX-4ontinued. *

Kans Report for Septeber, nn Hlstodes- tinuedL

Vaccination history ofcaw. New Viatd ast Place. Caes Deaths. Vaccinated vaccinated Ner His reported. moro than .suess- not - prceding7 ye 7 yeas fully taied or attack. preceding vanated.

Kanss-Continued. ; Pottawatomie County-. * Duluth.I...... Rawlins County- Luden...... 1...... Rie County- Little River...... 7...... 7 ...... 7 Sedgwick County- . Clear-ater...... Wichita . 10..10...... 10 hawnee County-

BoI a ...... X...... 3 ...... 2 Sherman County- Goodiandd...... 1 ...... Washinzton County- .... Washinon ...... 1 Wils County- Tredonia .10 i...... 7 3 Benedict ....1...... - I ''''''' '''''' ''.''''' 4 '''''''' Wyandotte County- Lan .sC . ..It 3 ...... 2

Total .'...... 3 2 A2 58

-Stte Rers for Augus and Sptember, 1920. rise. Cae. C nsUts.

Doelawe (August): Ohio (Stptember): Sussew County- Allen County...... l5..;...... Wtomn...... I ...... Butler County...... 9 ...... Co;hocton County...... I...... jaws (September): Clark County...... 1...... Adams County...... a ...... Crawford County...... 10 ...... AlhmankeeCounty. I ...... ahogaCty. 2. Booe County...... 17 ...... ae ce Cony ...... 3 ...... Clay y...... I ...... Payette County...... 7 ..:...... Ciaat Couty..... I ...... agmilton County. 20 ...... Clinton County...... Hardfn County...... 3. Da is ...... Knox County.... I County...... 3...... Decatur County...... Logan County...... 2 ...... Delaware Couty...... 2 ...... Lorain County...... 41...... Dubunue County...... 34 ...... Luas Couinty...... 3. 1 Fayette County...... Mahming Coumty...... 2 ...... 1 ...... Marin County ...... Franlin County...... 1 ...... FremouCounty -- 2 ...... Merer County...... 1 ....;...... Grundy County...... Slowm ColtltY.... -...... 2. 1 ...... Harrison County...... 2 ...... Henry County...... 3 ...... Morrow County...... County...... 2 ...... Ottdwa County...... asper I ...... Paulding ...... Johnson County...... 2 ...... County 2 ...... Jones County...... 1 Pikaway County...... LeeCounty...... Richiand Couty..... I.2 . on CouAy...... 4 ...... Ros County...... Scoto County...... 2 askaConty...... Senca County...... 1.1 Fsa ----* I...... CoantyCounty...... Stark County...... Summit County...... 2 ...... Po k county...... 2 Trumbull County...... I ...... 2 . PottawattamcC ...... Winiam County...... 1 Ringgold County...... Wysadot County...... Scott Coumty...... 4 5 . . . Unimn County...... TotJ...... 1...... I W 6dloCounty...... 1...... 1 . W ebr0aunty ...... Virgini (September): Worth County. 1 County...... BucBL uinghmhan .County Total ' ...... Dlfwyn...... Lee counlty...... 16 ...... November 12. 1920. 2736 SMALLPOX-Conflnued. State Reports for August and September, 1920-Continued.

Place. Cases. Deaths. Place. Cases. Deaths.

Virginia (September)-Con. Loudoun(September)-Con.County- VirginiaShenandoah County- Leesburg ...... I...... t Seven Fountains . 7...... Norfolk County- Tazewell County ...... 4. Portsmouth ... I . Warwick County- Roanoke County- Newport News. . Roanoko ...... 1 .. Wise County...... 6 Rockin Count...... 4...... Morton...... ,...... Russell County - Wise.12 . Honaker ...... SctScott Coimlytj....;_F 2...... TTotal . 101' ; .

I City Reports for Week Ended Oct. 23, 1920.

The c3lumn headed " Average cases" gives the average number of cases reported.during the correspond. tng week of the years 1915 to 1919, inclusive. In instances in which the information is not available for the fuill five years, the average includes froni one to four-years.

Aver- 1920 Aver- Place. age -Place. age cases.ICases. Deaths. ases e t.

Alabama: Louisiona: Mohie...... (1) I New Orleans...... 2 Arkansgs: Michigan: Fort Smith...... 1 Battle Creek. 0 14 Califonia: Detroit ...... 4 13 Berkeley...... 0 5 Grand Rapids. (1) 1 Los An"eles...... (1) 2 Luling on. 0 I Oakland ...... -.-.- 0 2 9nu1lt !te. Marie. 0 3 Pasad a...... 0 1 Minnesota: Sacramento...... - 0 Dulluth ...... (1) *5 San Diezo...... 1') 2 MisAneapois ...... 3 35 San Frcisco...... (') 4 Ft. Paul. 2 9 Colorado: Wiona ...... 26 Denver ...... 8 4 Missouri: Pueblo ....: - 0 4 Iniepen4enee...... 0 2 Georria: KansasCity. 9I 8 Atlanta .... 1 4 St. Louis...... I 2 Idaho: Monitana: Boise...... (1) 1 Butte...... 1 Illinois: Great Falls...... (') 1 Bloomington...... /1 Missoula...... 2 XChicago...... 2 2 Nebroska: Danville...... (1) 2 Lincoln...... 2 East St. Los...... 0 Omaha...... 2 Elgin...- (1) 1 North Dakota: 1 1 Fargo...... 5 Jacksonville...... 1 Kewanee...... Grand Forks...... 1 Rockford...... 0 15 Ohio: Indiana: Akron ...... (') 18 Hammond...... 0 3 Allianee...... litmtington...... 1 Clevelan ...... 13 5 Indianapolis...... 2 Middletown...... (I)0 I Marcn ...... 4 S1prgfield...... 0 Mishawaka...... 4 Yaungstown...... 3 1

SoutILBend...... 6 O(regon: Terre Haute...... 0 1 Portland ...... 2 7 Iowa: South Dakota: Cedar Rapids...... 1 2 Sioux Falls...... (1) 3 Clinton...... 2 Tennessee: Council Bluffs...... 1 1 Johnson City...... 3 Davenport...... 3 5 Memphis ...... 1 Des Moines...... 0 2 Ustah: Dubuque...... (1) 14 Salt Lake City...... 2 14 Iowa...... 0 3 Vermont: Mrshalltown...... 13 1 Rutland ...... 0 8 Sioux City...... 2 1 WVashhton: KAnsas: Hoquiam ...... 1 *1 Wichita...... (1) 3 Sttle...... 9 4 Kentucky: Spokane...... 5 6 Lesington...... 0 I Tao ...... 0 4 I Average less than 1. 273T8 ,November 12, 192G. SMALLPOX-Continued. City Reports for Week Ended Oct. 23, 1920-Contigued. 1920 Aver 152 Aver- ~~~~~~~~~~~1920- Place. ace Place.' age cases . asc. Deaths. cases.Casese.aths. Washington-Continued. Wisconsin-Continued. 5 Weila Wala ...... 2 .ree.ay. 1reBaay ...... 1 y . Yakima ...... I 1 Koaosh ..-...... _..__; (1) 1 .*. West Viriia: LaCrosse . 36 .i. Bluefied,.d...... 0 1 I Milwaukee . ... 2 38. Clarksburg ...... 5 ...... 5 Wcoslain: ...1Wyoming:eboygan .1... ApEton ...... 0 1 | Cheyenn ...... O 1 EauClaire ...... IAverage less tho L. TETANU8, City Reports for Week Ended Oct 23,-1929. Plac.- Cases. Deaths. Place. Cjases. aths.

New cN i1 1 ,,ork: NesUaven;.z...... 11. v efl,enmens FallsFals ...... -.. 1.? Stamford. 1 . 'New York.I 1 Ilinois: WhitePlain}.; ;1 ,1 Chicago ...... 3 2 Penslvania: Philadelphia.1 2. Pontiac. I I South Carolina: New Jersy: Spartanburg. 1 Atlantic City. 1

TUBERCULOSIS. Se¶'Ielegrphic- weekly reports from States, p. 2722, and Weekly reports from cities, p. 2742. TYPHOID FEVEX Salem, Ohio. An epidemic of typhoid fever has been reportkd at Salem, -Qhio. The number of cases reported October 14 to November 10 was 473. State Reports for August and September,. 1920.

Place. Neireported.*itge ______Place. Newreported.cases

Connecticut (September): Connecticut (S mber)-Conttnued. Fairfield County- New Haven- ty- Bridgeport...... 7 Branfd...... 1 New Canaan...... 1 Derby ...... 1 New Fairfield...... 1 New Haven...... 11 Norwalkl...... 4 Orange...... 1 Wilton...... 1 Waterbury . 1 Ilartford County- Wallingord...... 1 Bristol...... 1 New London County-. Enfoeld...... 37 Groton...... I Farmin,gton...... New London...... 1 Hartford...... 2 Stonington....;....;...... 1 New Britain...... Windham County- Newington...... Killingly...... 2 Plainville ..... II Putnam...... 1 Windsor...... Litchbfield County- Total...... 131 New Hartford...... Middlesex County- Fast Hampton...... 2 Delaware (August): Middleton...... 2 Kent County- Saybrook...... 1 Harrington (town)...... 1 1571'2° 20 5 November 12, 1920. ' 2738 TYPHOID FEVEROntinued. State .eperts for Augut ad September, 1920-Continued.

Place. Newreported.caes Plao. - PNweasesreported.

Delaware (August)-Continued. Kansas (September)-Continued. New Castle County- Finney Countj- Middletown (town)...... Garden City...... 2 Newark (town)...... n^'alls...... I Wilmington...... 4 Ford County- Sussex County- Backlin...... I Laurel (town)...... Dodge City (4RFD)...... 4 Franklin County- Total...... 8 Pomona...... _ I Geary County- . Delaware (September): ;.f tioncity ...... 2 Kent County- Gra%County- Ha-rington...... 2 Ciiimarron ...... 3 Houston ...... 2 Harper County- New Castle County- Harper...... 4 Middletown . .s...... ,.1 Jackson County- Newirk...... 3 Holton...... 2 Wilmington...... 4 JewellCounty- Sussex County- Randall...... 2 Oak-Grove...... Johnson County-- Seaford . .. Merriam. I Kiniman Ceunty- T.tal. .;.- 14 Kin-man...... 2 Kiowa County- 1 Kansas (September): 142 Haviland ...... Allen County- Labette County- oloi...... 2 Parsonsr. 3 Atchison County- Leavenworth County- Atchison (IEFD)...... 2 Kickapoo ..--.. --...... 'i' Barber County- Lea -enworth...... I Kiowa...... 1 Linn County- Barton County- Mound City ...... Great Bend...... 3 Pleasanton...... I Bourbon County- Lyon County- Uniontown...... I Oloe...... 4 Fort Scott...... 1 Reading...... 2 Brown County- Allen...... 6 Horton...... 3 Americus ...... I Butler County- Admire...... 1 Gordon. 1 Emporia...... 2 Towanda. 1 Marion County- Stone Park ...... Florence.Flrne...... 2 D,ougs...... McPherson County- El Domado...... McPherson...... 1 Chase County- Meade County- Cottonwood Falls...... Meade.. 1 Strong City...... 1 Mliami County- Bazaar...... Oskaloosa. 5 Clements...... 1512 Montgomery County- Chautauqua County- Cherryvale...... El-n...... Coffeyvlle...... 4 Sedan...... Morris County- Elk City.. 2 Council Grove...... 3 Cherokee County. Nemaha County- Columbus...... 1 Bern...... 1 Cre3tline...... 1 Sabetha...... 1 BaAter Springs...... 1 Neosho County- Chetopa...... 1 Erie...... 1 Galena...... Osage County- West Mineral...... 1 Lyndon...... 1 Scammon...... 2 Overbrook...... 1 Cowley County- Osborne County- Udall...... 1 Osborne...... 1 Elk City ...... 1 Pottawatomie County- Winfleld...... }1 St. George...... I Crawford County- Pratt County- Radley. Pratt...... 1 .Ringo...... Coats.. 1 Pittsburg...... Reno County- Decatur County- Hutchinson. 6 Norcatur...... Republic County- Dickinson County- Belleville...... I AbUline...... Riley County- Hlerington...... Manhattan. 1 Donihan County- Rooks County- ood ...... Webster...... 1 White Cloud...... Saline County- Ellsworth County- Bridgeport ...... 1 Langley...... Salna...... IL 2739 November 12, 1920. TYPHOID FEVER-Cntinued. State Reports for Augst and September, 1920-Coiitinued.

New Place. Ne mes1N ew cases Place. reoredeases reported.

Kansas (September)-Continued. I Ohio (September)-Continued. Sedgwick County- Morrow County ...... 1 Greenw rich...... 1 Muskingum County...... 4 Cheney...... ,1 Paulding County...... 2 Valley Center ...... Plekaway County...... 12 Wichita...... 9 Pike County...... 3 Shawnee County- Portage County...... 3 Richland...... 1 Preble County...... 3 Topeka (1t t. F. D.)...... 17 Putnam County...... 3 Smith County- Richland Cotmty ...... 4 I.ebanon...... 1 RossCounty ...... 9 Stafford County- Sandusky County...... Stafford... 4 Scioto County...... 13 St. John. 1 2 Sumner County- ShelbySenecaCounty.County. 2 Conway Springs...... 6 Stark County...... 5 Mulvane ...... : Summlt County. 36 Riverside...... i3 I Tnunbull Co nty...... u 9 Rome...... 1 Van Wert County...... 3 Wellington. 2 Warren County...... 2 WLls3n County- Waye County...... 2 Fredonia...... 1 WilliamsCounty...... 4 I Nexdesha. Wood County...... 7 Wyandotte County-...... Kansas& ity-...... G Total...... 494 Total...... 221 Virginia (lcptember)' Ohio (September): Accomac County . : 7 Adams County...... t Harhorton ...... 1 Allen County...... 7 Onancock . '. Ashland County...... 1 Tan,ier...... 1 AshtabulaCounty...... 9 ,Abemarle County .... 10 AthensCounty...... 5 Alexandria County- 6 AuglaizeCounty...... 7 Alexandria . Belmont County...... 3 Alleghany Coumty...... 3 Brown Ca3inty...... 9 Clifton Forge...... 6 Butler County...... 9 Covin"ton...... 3 Chamraign * oUnty...... 5 Appomattox CountY...... 1 Clark County. .. 7 AugustaCounty...... 7 Clermont County...... 4 Basic ...... 1 Clinton County...... 1 Fordwick...... 2 C,olumbiana County...... 8 Staunton ...... 1 Crawford (Coumty...... 7 Bath Cotunty...... Cyuahoga County...... 32 Bedford County...... Drake CountY...... 1 BedfordCity ...... 12 Delaware County...... 3 Botetourt County- Erie County...... 1 Troutville...... 1 Fairfield County...... 3 Brunswick County...... 3 FavetteCounty...... 6 Buckingham County...... 3 F Inklin C9unty...... 8 Campbell Countv- Fulton County.- 7 Altavista...... 2 Gallia County...... 1 -Brookneal ... 3 oreene County...... 4 Lynchbur'...... 6 Guerney ( ounty...... 2 Caroline County...... 1 Hairrilton County...... 16 CarroltCounty...... 2 Hancock County...... 2 Charlotte County...... 4 Hardin County...... 12 Chesterfield Counity...... 7 Henry County...... 19 Culrerer County...... 1 Highland County...... 2 CulTeir. .. 2 1 4 Hocking County...... Dickenson County ...... HolmesCounty. 1 Clintwood...... 2 Jackson County 2 Dinwiddic County...... 4 KZnox County . * . 3 Elizabeth City County...... 1 Lake County...... 1 Hamuton...... 1 .. Lawrence CountY . 5 Phoebus...... 1 Licking County.. Essex County...... 4 Logan Coujnty...... 3 Fauquer County...... Lorain County...... 5 Renungton. ; Lucas County...... 14 Floyd County ...... 1 Madison Couinty...... 1 Floyd...... Mahoning Cotnty. . 12 FluvannaCounty... MarionCounty...... 2 Giles County...... Marion Conty...... Medina County...... 6 Grayson County. 3 Mercer County...... 6 Greene County...... 5 Miami County ...... 70 Halifax County...... Monroe County...... Hatnover County...... Montgomery County...... 9 Henrico County...... 9 Morgan County ...... 2 1 Ri ond...... 13 November 12, 1920. 2740 TYPHOID FEVER-Continued. State Reports for August and September, 1920-Continued.

New c Plrae. reported. zNwasesreotdPlace. reported.

Virg ia (September)-Continued. Virginia (September)ontinued tienry County ...... 3 Rockineham County- Bassett .... 6 Bridrewater . Martinsvile .... 2 Harrisdnburg 1.. James City County...... 4 Russell County ...... 10 Williamsburg .... II Honaker. . 2 King and Queen County .... 9 Scott County. 3 King Georre County ... . 1 Gate City...... 4 King William County .... Shenandoah County ...... 3 LancasterCounty .... Smyth County 5... LeeCounty .... 4 Marion. 2 St. Charles...... 1 Southampton County. . 10 Loqdoun County...... 2 Boykins ...... I Louisa County .... 3 Stafford County...... 2 Lunenbure County . .. 2 Surry County .. Madison County ...... 5 Sussex County. .1...... Mecklenburg County...... 2 Tazewell County .. Mont!'omery Couinty .... 6 North Tazewell .. Radford...... 2 Warren County .- 1 Nansemond County ... . 5 Warwick Coumty ..1 Nelson County...... 2 Newport News.. 4 Norfolk County- ^Washinrton County 9 Norfolk ... 3 Bristol. . I Portsmouth ... 4 Westmoreland County . . 7 Nofthumberland County.... I WiseCounty ...... 4 PittsylvaniaConty ...... 2 Anpalachia1 . . *Po*hatan County...... 4 Birstone Gao.. Priniess AnneCounty i East Stone Gap .. Prince Edward Count 1.... Osaka...... I Pulaski County...... 2 Wythe County .. . 2 Roanoke County ... 3 Roanoke.13... 13 Total . . 359 Salem... 1 Rockbridre County- Buena Vista .... 2

ity Reports for Week Ended Oct. 23,. 1920. The column headed "Average cases" gives the avorage number of cases reported during the corresponding week of the years 1915 to 1919, Inclusive. In instances in which the information is not available for -the fullfive years, the average includes from one to four years.

Aver- 1920 Aver P Place. age Place. age cases. cases. Cass.D3hqs ets .Deatls. _ Alabama ' Bessemer...... I 1 Idaho: 1 Birmingham...... 1 IllinoisBoise . 0 Arkansas: Alton . 1 Fort Smith...... 4 Aurora ...... Little Rock...... 5 2 Bloomington ...... 1 1 Calitornia: Chicago ...... 1S 12 1 Los Angeles...... 5 2 ...... Danville ...... 1 2 ...... Oakland ...... 4 East St. Louis ...... 0 1 Sacramento. L a e ...... a 1 San Francisco...... Mattoon ...... 0 Ivi1 Colorado: Quiney ...... 0 1 Denver...... 1 Indiana: Connecticut: Bloomington ...... 0 1 Frankfort ...... Bridgeport...... Hartford...... 2 Gary ...... 31 New Haven...... 3 Hammond...... 0 1! ...... Delaware: Indianapolis ...... 5 1 .2 Wfilmi on ..q...... 2 ...... Kokomo ...... 1 ...... Distriet ofColumbia: La Fayette ...... 0..... O ...... - Washlngton...... 10 2 Marion ...... 0 I .. . . Georgia: Richmond ...... rAtlanta...... 2 5 Towa: ...... Rome...... 0 1 ...... urlfngton ...... 0 3 ...... Savannah...... 2 1 C RdaRapids...... 0 1 I Average less than 1. 2741 November 12, 1920. TYPHOID FEVER-Continued. City Reports for Week Ended Oct 23, 1920-Contipued.

.s1920 1920 Aver- Aver- Place. age rlace. aze cases. Cae Deaths. cases. cask-n. DestbLs,

Iowa-Continued. I New York--Continued. 'Clinton ...... 0 1 fomnell 0 1 Muscatine ...... 0 1 Ithaca 0 Kansas: Ne- v York .51 ...ii., Iltchinson ...... 0 2 Poughkeepsie. 1 I Kansas -ity...... 2 I 1.... Rocheter. 2 1 Topea...... 2 Syrausee 1 1 .i4 Kentucky: 1.... North Carolina: 1 Luisville...... 2 4 Durhamr.. 1 Paducah...... 3 Ral'i h ...... 0 1 ..... Louisiana: 4.... Winstcn-Salem ..1...... 1 New Orleans...... 11 4 Ohio: Maine: Bar'erten ...... 1 Bangor ...... 2 Cincinneti . . 7 I ..... Portlad.....l...... 1 Clevel nd .. 6 2 Maryland: Daytf n.. 2 2 Baltimore ...... 21 9 Lanraster .. 2 1 Cumberland ...... 1 1 Lorain...... ,,,.(1) 1 Massachusetts: Marien ...... I 7 Beverly...... 2 1 1.... Middleto-n...... O 1 Boston ...... 5 1 1.... Piqua . .1...... 2 Chelsea ...... 1 1 Portsmouth ..1...... 1 Danvers...... 0 -1 Toledo...... 6 6 Everett...... 1 1.... Oregon: Fall River...... 70 1 Portland...... 3 2 Haverhill...... 1 ..... Salem .. 0 I Lowrell...... 2 1 Pennsylvania: Lynn.n ...... 2 1 Allento n...... 1 3 New Bedford...... 3 -3 'Beaver Falls . . 0 1 Pittsfield ...... 1 Butler ...... 2 3 Somerville...... 2 1.... Chcster...() 2 Taunton...... (1) 2 Erie ...... 6 1 Worcester...... 2 1 Meadville ...... 0 1 Michigan: 1.... Philad.lIt hia . . 16 14- Ann Arbor...... 2 ...... Scranton ...... 0 1 Cadillac...... 0 Washin tcn .. 2 3 1 Detroit...... 12 ..... Yorkc ...... 4 1 ..... Kalamazoo...... (1) Rhode Island Port huron...... Y 1 Providence ...... 3 Saginaw...... 4 Tennessce: Minnesota: Knoxville ...... -2 3 Duluth...... (1) 2 Nashville ...... 7 1 Mankato...... 0 2 Texas: Minnearolhs...... 3 3 Austin...... 0 St. Paul...... (Q) 3 Beaumont .. 0 Missouri: ..... Dallas...... 2 2 KansasCity...... 4 1 El" aso...... 2 3 St. Joseph...... (1) Galvestcn...... 2 St. Louis...... 7 6 Houston ...... 3 1 Montana: Waco...... O Billings...... 0 . ...i. Utalh: Great Falls...... 3 Salt Lake City .. 3 1 Nebraska: Vermont: Lincoln...... (1) 1 Burlinrton ...... 0 1 Omaha...... (l) 1 Rutland ... ( 2 New Jer;ey: Virginia: Atlanti City...... (1) 1 Danville ...... 0 1 ...1. EliLal eth...... Portsmouth...... ).() El ood ...... 0 1 Richmond ...... Hoboken...... 0 1 4 Jersey City...... 2 2 Washin-tcn: Morristo-n ...... (1) 1 Seattle...... (. ) 1 ...... Orane ...... 0 1 Spokane...... 0 3 ...... Plainfield ...... 0 1 WallaWalla ..1...... 1 ...... Trenton...... 3 1 WecstVkAnia: New Mexico: Bluefield ...... 0 4 Albuquerque...... 1 Iluntin tcn ...... 1 New York: Mor-antown.. .4 0 2 Albany ...... 4, Wheeling ...... 2 2 Aul)urn...... (I) 1. Wisconsin:.. 2 Buffalo...... 5 Milwaukea ...... 0 I 1 Cohoes...... 0 1. W^auisau ...... | 1 I I Average less than 1. November 12; 1920. .2742 TYPHUS FEVER. Temple, Tex. Under date of Novemnber 4, 1920, one case of typhus fever was reported at Temple, Tex. DIPHTfHERIA, MEASLES., SCARLET FEVER, AND TUBERCULOSIS. City Reports for Week Ended Oct. 23, 1920.

tioni as of Total fever. eulosis.

City. (estimatedbU. S. fromall Bureau). 3

Adams, Mass...... 14,406 ...... 14 ...... Akron,Ohi...... 93,604 26 10 ....3 ....9.... AlameaCaif...... 28,433 6 1...... 1 1. Albay,.I...... 106,632 .....7 7..... 4. AlbtRquerque, N. Mex..... 14,509 7 5 ...... 4 4 Aexandria,La...... 16,232 10 -...... Alx4ndria,.Va...... 17,959 3 ...... A.lentown, Pa..... 65,l0...... 3 ....10 ...1. ... 2. Allianee Ohio. 19,58L ...... 2...... to ...... 10 1 Altona,P..... 593,712 . 3 ...... 2...... Ameibury,.Mass. . . 10,200 1...... 4 ...... Anaconida, Mfont. 10,631 4 ...... 1 ....1... Ann Arbor Mic . . 15,04.20 ..1 Arl3ing3on,...a.s.I13,073..1.... 2 ....2. Asbury Parlk, N.J...... 14,629 3 ...... Ash'and Wis...... 11,594 ....1...... Ashtabu'a 'Ohio...... 22,008 2 1..I ... 1...... Atchisot,kans ...... 16,785..... 4...... 2...... Atlanta,Ga...... 196,1',% 48 13 1 2 1 4 1 6 . AtlanticCity,N. I ...... 55,51in 8 4 1 ...... 1.... Att eboro mass...... 10,776 5...... Auburn,We ...... 16,607, 6 ...... 1. AubtimnN.Y...... 37,823 16 1... 1...1...... 1 Aurora[lM.l...... 34,795 8 ...... 1 Au%fln,Tex ...... 35,612 10 2 ...... 1...... Bairerstield Ca'if . . 17,543 7 2 ... 4...... 5 . Balt#ore td.. .594,637 149 59....55 18.. 23 I ... Bangor, M...... 26,958 ...... 3 .... 1...1 Barberton, Ohio...... 14,187 4...... 1... BattleCreek, Mich...... 30,159 .....4 1...... BayonneN.J.. ...72,204..10 ...... 7 1. Beacon, MYT...... 11,674 6 1 ..1 Beatrice, Nebr...... 10,437 2 ...... Beaumont, Tex ...... 28,851 6 ...... Beaver Falls, Pa ...... 13,749...... 2. 1... Belleville, N. J3...... 12,797...... I ...... t...... Bellingham, Wash 34,362 1....4...:.' . Beloit,Wis...... 18,547 2 1...... 1I...... Benton Harbor, Mich...... 11,099 2 1...... 1...... Berkeley Calif...... 60,427 14 1....I...1. 4...... Ber:i,NM.H...... 13,832 0...... 3...... Bessemer Ala. . 17,156 9 5...... 1... Beverly, ifs:...22,128 3 ...... Biddeford,Me...... 17,7160...... 4...... B illings, Mont...... 15,123 6 ...... 15 ...... Birmingham, Ala...... 189,716 58 13 .... 1 .... 5 .... 5 . 2 Bloomfield, ...N....19,013. 2 ...... Bloomingtn,Ill ...... 27,452 9.. . 5 ....6.... BomingonInd...... 11,661 3.....2...1... Bluefiel4W.a...... 16,1i2.3..... 8 ...... 1...... Boise, ..daho ...... 35,951 ...... Boston, Mass...... 767,813 173 49 2 3 68 j Braddock,Pa...... 22,060...... 1...... Bradford,Pa...... 14,54A4...... 4.... 4...... Brazil, Ind...... 10,472 0 ...... BRdgeport,Conn...... 124,724 29 13 .... 4 .... 4 .... 7 . 2 Bristol,Conn ...... 16,318 ..... 5 ...... 1 .... Brockton,MIkass...... 69,152 14...... 2 .... 1. Brookline. Mass...... 33,526 5...... I...... 1 1. Brunswick, Gs...... 10,984 3.1..... Buffalo, N. Y...... 475,781 107 0 g9. 97. 9 15 j9 'Population Apr. 15, 1910. 2743 ~~~~~November 12,-1920. DIPHTHERIA, MEASLES, SCARLET FEVER, AND TUBERCULOSIS- Continued. City Reports for-Week Ended Oct. 23, 1920-Continued.

I Popula- - Diphtheria. Me sg irlet Tuber- ases feirer. culosis. JulvIyl,1917tion as of deaths-Total city. (estimated from bv U.S. all . Census causes.. 9 Bureau). I I I ~i A 0

Burlington, Iowa ...... 25,144...... 1...... Butngton,Vt ...... 21,802 7.1...... Bte,P...... 28,677 ...... %-6....1. 1...... But,Mn...... 44,057' 21 ...... 90...... CailcMc.10,158.....l" 4 2...... 1I.... Cam rdemass...... 114,29.3 31 4.... 1 ... 3 .... 4 3 Canton, Il...... 13,674 3...... Cape Gimardeau, Mo...... 11,.li 146 5 3...... 2 .... 1 1 Carbqnda'e, Pa...... 19,397...... 6.... 2...... Carnegie,Pa ...... 11,958 .....7...... 6 ...... Cedar Rapid, owa.... 38,033 .....5...... 2...... CeItItmIiS,I I . 11,838- 2.... Charleston,S.C...... 61,041 22 2. ..2. 1.. Char'eston W.Va ...... 31,060..... 3. 1...... Charlotte,14.C ...... 40,759 10 9 11 I ... 9..j Cclsea,Mass ...... 46,405 9 8....7. 1.. ... 1.... hester,Pa ...... 41,8K57.... O...... 6. 3 ...... -Cheyn, Wyo...... 111,320 2 j;. 1 ...... Chi fit...... 2,547,201 492 238 9 38.... 134 1 229 29 Chicopee,Mass ...... 29,950 9... 1I...... ChUllcothe., Ohio ...... 15,625 4...... 4...... Cincinnati, Ohio ...... 414,248 88 23 3 5 .... 10 .....1.1 Clarlrsburg, IV. Va...... 12,960 ...... 4....I...... 2 ...... Cle-veland Ohio...... C1092,259 155 54 1 5 .... 62 .... 2 7 Clinton,Raw...... '.... 13,075 2...... j...... Coateavile Pa ...... 14,99A8 .....2.1...... I.... COffeyville Kans...... 18,331 1 2 1...... Coho".Y...... 25,292 6...... 16 ...... ColorAo Spings,Colo...... 38,965L 13...... 4 .... 1 I Columibia C...... 35,165 3...... 1 ...... Concord, .....H.I .....22,858 1...... 1...... 1...... Corpus hrst Tex...... 10,789 6...... 1.. .Cortiad,.V...... 13,321 4 1.... 1 ...... 1...... I Council Bluffs rowa ...... 31,838 8 1...... 6 ...... 1 Cranston R.1'...... 26,773 I4 1...... Crawford?sville, Ind ...... 11,443 2 1...... 2 ....1... Cumberland, Md...... 26,686 11...... 3 3...1 DalsTex ...... 129,738 30 34 2...... 3 ....14 3 Danvers, Moms...... 10 (037 ...... 3 .... Danville, Ill...... 32,969 4...... Danville; Va...... 20,183 3 4...... 1 ...... 1 DatnOhio ...... 128,939 44 13...... 7.... 2.... Dedham, Mass...... 10,618 2...... Dcver,Colo ...... 268,439 69 41 5 5 ....3 ...... 13 DsMoines, Iowa...... 104,052...... 5...... 10 .... 1.... Derit Mich ...... 619)C1 17 13 9 .... 0 8 90 Dover,W H ...... 1 172 135.. 8...... 18..... Dubuque, Iowa...... 40,096 ..... 4...... j... 1 ...... Duluth, Mmnn...... 97,077 8 5.... I....1...... Duha, N.C ...... 26,160 7 3... I...... 2.1 EastChicago, [ad...... 30,286 6...... 1 Eas Cleveland Ohio ...... 13,864 .....6.1...... I.... Easthampton, liass...... 10o,656 ...... 2 ....1...... Easton, Pa ...... 30,854.-----3...... Eaqt Oran'ge, N.Ji...... 4.3,761 7...... 2.... East St. Louis,ll1...... 77.312 10 4 1...... 2 ... 1 1 EauClare, Wis...... 18',987 .....3...... 1 ------Elgin 11 28,562 5...... 1. 2 .---. FAiZalth`-N- ...... 88,839..... 6 ...... 5.... 2.... Elkhart, ad. . 22.273...... 1. 1 ...... Elmira, N. Y...... 38,272 1 1....-...... 1...... IlPwso,Tex...... 69R,149 26 2 1...... 1I...... 7 Elwood, Ind ...... '11,028 4...... Englewood, N. I3...... 12,603 2...... 1...... Erie, Pa...... 76,592 .....11 ...... 22 ...... 8.... Eureka, Calif ...... 15,142 3 1...... 1 ....1.... Evanston,.iIl...... 29,304 4 1...... Evansville lad...... 76,981 21 13 I1....1....I...... 2...... Everett,Mass...... 40,160 7 lJ ...... 3 . j Fairmont, WV. Va...... 16,111 . FaURiver,Maws...... 129,828 40122...... 2 8 12 4 Population Apr. 15, 1910. November 12, 1920. 2744' A DIPHTHERIA, MEASLES, SCARLET FEVER, AND TUBERCULOSIS- Continued.

City Reports for Week Ended Oct. 23, 1920-Continued.-

Popula- Diphtheria Measles. Scarlet Tuber- tion as ot Total fever. culosis. JulyC,1917 deatbhs. City. (estimated from f*1 u(e1sus causes. U Bureau). i 0

3%argo Dak...... 17,872 5 2 2 .*,... farre,'Pa...... :...... 110,190 5 ...... Findla: Ohio...... 114, 858 4 ...... FRlinlt, job...... 57,386 17 19 ..... 2 1 Fondda Lao Wis -...... 21,486 ';''' : ... Fort S3cott Reans. 10,564 16 ...... , ...... Fort Snlit, Ark...... ' 29,390 6 1 ..... Fort Worth, Tex...... 109,597 4 ..... Framlngham, Mass...... 14,149 2 1I ..... :::i.: Frankftort, Ind...... 10,103 3 3 ...... i. Freeport, Ill...... 19,844 9 1 ..... From nt, Nebr.... 10,080 4 1...... Fremont, Ohio...... 11,034 2 1 ..... Fresno, Cal...... 36,314 .... .I ..... Galeeburg, Ill ...... - . 24,629 6 3 1 ...... Galveston Teox...... 42,650 8 ...... i. .i. Gardn, ...... 17,534 2

d 56,000 20 ''''i- ...... Geneva ...... NY ...... Y . 13,915 4 lw****v 1 GlensUslls,N 17 160 3 bew@vs ...... Glouester, City, N. . 11 375 o**@*- 2 2 ..... Grand Forks N Dak..... 16,342 12 o-ss*- 2 ..... Mich. 132,861 23 2 ...... Grand Rapids ...... 1 Granite City . 15,890 1 ...... 4.....1. Great Falls, iont.. . - 113,948 4 4 ...... Green Bay, Wis...... 30,017 7 1 .... 4 ...... Greenfield, Mass...... 12,251 3 7 ...... Greensboro, N. C. 20,111 6 ...... Hackensack N. J...... 17,412 8 1 ...... 3 ...... Hammond, id...... 27,016 8 2 ..... 3 .... 5 . .... Harrisburg Pa...... 73,216 8 ...... 3 ... HlarrX80D, §. J...... 17,345 ...... Hartford Conn...... 112, 831 34 10 .... 5 4 8 ...... HaverhiJi, Mass ...... 49, 180 18 ...... 4 2 Highland Park, Mich 33,859 7 2 I 3 ..... High Point N.C. 13,439 2 ...... 1 I.... Hoboken, 4. J.....-- ....-.--- 78,324 3 ...... 2 3i Holyoke, Mass...... 66,503 14 ...... 1 I...... Hot Spr , ...... 17,690 ...... 11,78 Houston, ex ...... 38 .... 1 ..... Hludson, N. Y...... 12,898 4 ...... Huntmngton,Ind ...... bd 10,982 ..... Huntington, W. Va...... 47,68i 11 1 ...... 2 Hutohinson, Kans...... 21,461 ...... 4 ...... Indepeadenee Mo...... 11,964 ...... Indianapolis, hid...... 283,622 76 7 1 10 12 17 Iowa City Jowa ...... 11,626 ...... Ironton, dhio ...... 14,079 ..... 1 .. 5 ...... Ironwood Mich...... 15,095 7 ...... 2 ......

Irvington, N. J...... 16,710 ...... 3 ......

-hpemig Mich...... 12,448 1 ...... 1 ...... Ithaca, N ...... 16,017 12 2 ......

11 ...... Jacksonvie Il...... 15,506 11 ...... Jamestown Y...... 37,431 7 6 ...... JanesviIle .i...... ; 14,411 ...... Jefferson it Mo...... 13,712 ...... 2 ...... Jersey Cit J...... 312,557 .... 2 2~~~~~ ...... Jo son iy Ten...... 1,'8 ...... 2 ...... Johnstown, a ...... - 70,437 6 3 Joplin, Mo...... 33,400 4 ...... 1 3...... 3. Kalamazoo, Mich...... 50, 408 ...... I ...... Kansas City, Kans...... 102,096 17 14 1 Kansas City Mo... 305,816 18 S ... 15 ...... 5

3 ... erny...... 24,325 ...... Keene N H ...... 10,725 2 ...... ~~. ....0 22 XenoshaK...... 32,833 ...... Keno6ak,Wisxra...... 114,008 1 ...... I 13,607 3 ...... X5...... Knoxcville,Kewanee, Tenn...... 59,112 ...... Iroptlation Apr. 15, 1910. 2745 No-rember 12, 192. DMPHTHERIA, MEASLES, SCARLET FEVER, AND TUBERCULOSIS- Continued. City Reports for Week Ended Octe 23, 1920-Continued..

arlet ITuber- Popula- Diphtheria. Measles. Sfe ver. culosis. tion as of Total uly l, 1917 deaths City. I (4estinmated from by U. S. all @nsus- causes. a .: Bureau).

Kokomo, Tnd...... 21,929 *4...... Lacawanna, N. Y...... 16,219 4 1. 15. 3

La Wis 31,833 ..... Crosse, ...... :...... La Fayette, Ind ...... - 21,481 8. 3 Lake Charles La...... 14,930 2...... ii*...... 1*** ...... Lancaster, o6i 16,086 .1......

Lancaster Pa...... 51,437 26 ... .. -.***.

La Salle, ill...... 12,332 6...... > *o* Lawrence, Kans...... 13,477 4 1 1...... 1 o**** Lawrence, Mass...... 102,923 28 7 3 7 5 2 Mass. ***.@- Leominster, 21,365 2 ...... 2 Z*.v** 2. Lexl.ugton, 41,997 11 Ky...... 1...... 2 v-***@ 3 Lincoln, Nebr...... 46,957 10 2 wso-*e Little Rock, Ark...... 58,7165S,716.....~~~...... 6 w* Lockport, N. Y...... 20,028 6 ...... 2 ****ew Logansport,Ind...... 21,338 2...... 3 oF**** Long Bseach, Calif...... 29,163 15 1...... os-v** 9.' Ohio...... Lorain, 3',266 ...... 3...... 2 **s@* ...... 3 LOB Angeles, Calif...... 535,48.5 155 39 2 5 s***o 50 21 Louisille, Ky...... 240 FnS .62 9...... 11 P*vev...1.8 ...... 8 Lowell, Mass...... 114,3666 ...... 0.l 2 1 7 oP*v@* Ludington, Mich...... 10 566 4 ...... X**@ve Lynchbr, Va...... ***so ynn, 33,497 S ...... i...... Mas...... 104,534 19 3. -v*@e . 31 ...... a McKdsont,W ...... 48,299 ..... 1...... McKees Rocks, Pa...... **v* 20,795 .1......

Macon, Gasi...... 46,099 15 78 1 ...... 21 .. . . owev 3 ...... 3

Madison, Wis...... 2.. . 31,315 ...... Mahano ocity,W @*** ...I...... Malden, Massi ...... 10 4 ...... 2 Manchester, 52,243 ov=ww N...... 79,607 18 26 .1.. . .. | ...... **** ...... Manitowoc, Wis...... 13,931 ...... 2 *-o** Mankato, Minni...... 110,365. *@v@ Marion, wd.. . 19, 923 103 ow-** Marion, Ohio...... 1 ,1 ...... Marquette, Mich...... v*s*w ...... Marshal ltown owa...... **wow Martinsburg, iv'...... Va ...... Mattoon, ...... se*sv ...... **v6o Medford, Ma...... **oow Melroset mass...... 17,724 5...... v Memphs Ten...... 151, 877 43 47 2 5 a*vv@Z 7 5 M eriden,C onn...... ***ZX ....l1.2 .... .-.4 Mlethuen, MasKs...... 14,320 4 1 ...... 1...... Middletown, N. Y...... o 15,890 1 4 4 ...... n, vosev 1 ...... Middletow ohio...... 16,384 ...... 2 Milwaukee, Wis...... 445,008 76 67 4 5 ...... 2 ...... Minneapolis, Mian ...... 27,):087 . . 43 -47 2. I ...... l 26 6 Mishawaka Ind...... 22 25 ...... I...... Missoula, iont...... 3327,44859,201 59 1. 3 ...... 1 Mobile, Ala...... 2.i Monessen, Pa...... 1 . Monmouth 111...... 23,0704 . .... Montclair, J...... MWontgomery, Ala...... 44,039 4 .^ 1 -3 Mlorgantown UW Va...... Morristown,hN.J...... 1341 1......

Moundsville, W. Va...... 11,515 3...... Mount Carmel, Pa...... 20, .. 4 ...... 1 Mount Vernoin, N.Y...... Muncie,Ind...... Museatine, Iowa...... 2 Nanticoke, Pa...... 23,8114 4 ...... Nashville Tensi...... 1181036 42 17.....4. J Newark, ...... 418,789 1 35 10 New Bodford, Mass...... 1525,855 ..25 ...... I...... 6 2 Now Britain, Conn...... New Brunswick N. J...... Nowburgh, N. V...... 29,893 5 2..i. 1.....I l3Population Apr. 15, 1910. Nlovember 12, 1920. -2746 DIPHTHERIA, MEASLES, SCARLET FEVER, AND TUBERCULOSIS- Continued. City Reports for, Week Ended Oct. 231, 1920-Continued.

IPopula- Diphtheria. Measles. Seaxlet Tu ber- tion as of Total f rer. cullosis. July1,1917 deaths City. ~(estimasted from City I ~~byU.S. all ~ . ICensus causes. -04 i 0 Bureau). Q U Newburyport MAass . 3 New H ven, onn ..... 152,27515,291.... 4 ... 1 15 New () eans La . 3177,010 110 4114 ....10....8 1 15615.37... NeW Phiaeiha, Ohi . 1,133..... 1...... Newpot, I30,585 0.1...... I...... Nowoi,as44,343 8 5 ....35.... I.... . NewYo, ...... 5,757,492 1,091 255 12 33 1 115 3 1301 91 Nla*ardFalsN. Y....----38,466 15 14 ...... 9 ....2 1 Norfolk, a...... 91 148 1...... I... 3 2, Norristown,Pa ...... 31,969 ...... 1. 3 ...... North Adams, Mass...... 222,019 5 ...... 1.1...... Northampton, mass ...... 20,006 6 3...... 1.... NorthAttleboro,Mass ...... 11,248 6 1 1...... 1...... North Braddock, Pa ...... i84..... I...... 1.1...... North l~ittle Rock, -Ark ..... 16,515 I 2...... 5...... North T'onawaada,N Y..... 14,OC0 5 1 ...... I...... 1I Norwalk,Conn...... 27,332, 6 2...... 1I......

Norwood, Ohio...... 4.8.....2129 ...... 1...... Oakland Calif ...... 23,405 4...... 1 3 Oak Parn l...... 27,816 10 3...... I.....1 2 1 Oilcitv, P's...... 2001C2 ...... 7.I....10...... 1.... Oklaoma City, Okla... 97,588 16 14...... 1...... OldForlee Pa 15,479g...... 5.1... Olean,N. 'Y...... 16,927 2...... Omaha,Nebr...... 1i-77,777 42 12 4...... 4 ...1.... OraneeN I...... 33,e136 2.1...... 2.... I.... OthkOs6,WiS...... 3t5.549 13...... 4...... Padueasi, Cy ...... 25,178 ... 5...... ParkershNsir, W. Va...... 21,059 6 1 ...... Plarsos,Kans ...... --.-. 15 952.....15...... 4.... 1.... Pasadena,Calf ...... 49,f20 Passale,N.J...... 74,4778 86...... 6.... 5.... 1.... 1.... Paterson,N. J...... 14O,512 3 9....I...1. 2....-8. Pawtueket R I ...... 60,666 13 2 ...... 2 Pealrodvr ikass ..... 18,785 7 3 ...... 1 2 PeekskliNm.YK...... 19,034 3 3 ...... 2

PeorialI ...... 72,9184 19 2.... 2.... 11 ...... Perth...... 42,f'46 6 6.... I...1. 3.... 1...... 25,817 8 7...... 2 ...1 1 Pbiladeinia Pa...... 1i 735, 514 440 82 7 3 ....137 3 97 86 PhilUlrsbv,. I..... 1-5,879 5...... 1... 1 Thoenixvile Pa...... 11,871 .....3...... 1...... Piqua, Ohio...... 14,275 7...... 1 1 Pittsburgh Pa . 586,196 .....47.... 7....40.... 13.... rittsfield, kas:39,678 12 ...... 15...... 1 1 Pittston, 1...... 2.. Plain.field,P1a...... 18?975N. J...... 24,330 8...... I... rlattsburg, N. Y ...... 311 ...... Mas...... 14,001 ...... PntcMich...... 18,006 85...... 8....1I....10 ....10.... PotCetr N.Y...... 16,727 2 1 ...... Port Huron, Pi;h ...... 2 18,863 5 2 ...... Portland,Me ...... 64,720 23 2 1 10.... 2 ...... 2 Portland, Orer...... 308,399 54 21 .... 11 .... 14 .... 4 0 Portsmouth, Ohio...... 29,356 8 8...... 2...... Portsmouth Va...... 40,693' 12 7 1 2.... 1I...... Pottsville,ga..:...... 22,717..... 6...... Poughkeepsie,N.Y...... 30,786 11 4...... 1....2... I...... Prviebl Co.e, 259,895 44 14 3 8... .6... Quelc,IClo ...... 56,084 9 10 1... 1 1.... 1... Quiincy, Mass...... 36,832 7 2.2...... 10 2 . 2.... 4.2 RacioMass...... 39,022 ...... no i ...... 47,465 . 20...... 3....

Raleieh, N. C...... 024 15 ... 5... 3.1..... Readin-v, Pa ...... 111,607 ..... 2...... 2...... Redlti ds, Calif ...... 14,573 3...... 1...... Ileno, Nev ...... 15,514 3....2...... ZlUchmtond,Ind ...... 2, 3...... 2 . IPulmonary tuberculosis only, 2'Population Apr. 1s, 1910. 2747 November 12, 1920. DIPHTHERIA, MEASLES, SCARLET FEVER, AND TUBERCULOSIS-1 Continued. ..1- City Reports for Week Ended Oct 23, 1920-Contibmed.

Popula- Diphtheria. Measles. Scarlet Tuber- I C 3- ion as of Total , I ~~~~~fever. culosis. J,alvy , 1917 deaths City.( tstimated from bv U. S. all A Census causes. .0eV; 2 ~~~~~~~0; Bureau). IJI.II~~~~~~~~-£4.!esC I)4 . _~~~~~~~~~~~~~~~~~~~~~~~~~~~ e Richmwond, Va...... 158,72 46 50 ...... 12 7 Riverside, Calif. 20.406 3 ...... Roanoke, Va. 46,26Q2 6 ..... 4 .1 Rochester, N. Y...... 2r4,714 46 59 3 6 ''''i 17' Rockford, III...... 56,739 14 5 ..... 9 1 Roek Island. 111...... 2().4r2 1 ...... ,...... Rocky Mount, N. C...... 12,673 2 ...... 17 Rlome, Ga...... 15 f607 ...... 14 ...... Rome, N. Y...... 24.2-69 ...... lg ...... 2 Rutland. Vt...... 15.038 2 ...... 1 Sa,'ramento. Calif...... 68,084 22 ...... Sa-inawv. Mieh...... 56. 4'-9 16 2 ...... 5 ...... St. Cloud. Miam...... 12,013 ...... 2 ...... St Joserh. Mo...... 8A. 408 36 1 ...... St. Louis.Mo ...... 768,630 186 166 3 28 ...... ' i1 St Pauil. Minn...... 252.4"5 29 9 ...... 3 ...... Sa'em, Mass..- 49.346 9 1 ...... 23 Sa'cm, Ore"...... 21,274 5 ...... 10 ...... Balt Lake Citv, Utah...... 121. 23 19 23 ...... 2 ...... Ban Bernardino. Ca'if...... 17,6f16 8 2 ...... 2 San PiLeo, Ca'if...... 5. 412 24 1 ...... 20 Sandiskv, Ohio...... 20. 1221 3 1 ...... Sanferd. Me...... 11.217 0 1 !, ...... San -ranpisco, Ca'if...... 471.023 120 12 2 ...... Santa Rarbiara. Ca'if..... 15,3T0 7 ...... Satnts Cruz, C 'lif...... fis,10 8 ...... 2 ...... Sarato-a Brrin-s. N. Y. 13,89 4 ...... 8 Sault Ste. Marie, Mich.... 14.130 4 ...... 4 1 ea annah. Ga...... 69,270 32 10 ...... 92 ...... Scranten. Pa...... 140.541 ...... 9 2 ...... 1 Seattle. Wash...... 366,445 ...... , 12 1 5 ..... ,1 Shamokin, Pa...... 21.274. 1 ...... 4 ..... '2- Sharon, Pa...... 19,l-fi ...... 8 ..... 1.. Sheboyean, Wis...... 2Q,907 8 ...... 1 ..... Sioux Citv, Iowa...... 2 ..... Sioux ralls, S. ak...... 1688,7 5 1 ..... Somerville. Mass..------88,616 20 2 ..... South Bend, Ind...... 70.06-7 7 6 ..... 7 Southbrld-e, Mass...... 14.4e.5 2 ...... Spartanbi'ra, S. C...... 21.965 8 411 ...... -1 Spokane. Wash.... . 157.6F.56 ...... 4 1 Sprin7feld, Ill...... 62,623 ...... 2 3 13 Sprin,field, Mass...... 108,6C,8 27 3 9 1 Sprinmrield, Mo...... 41.1"9 11 ...... Sprinwfeld, Ohio...... 52,296 15 ...... 6...... 2 8 Stamfcrd, Conn. 31.610 ...... 1 3 Stalnton, Va...... 11,1-23 6 ...... Steelton, Pa...... 15.759 ...... Steubenville. Ohio...... 2R.2r9 7 19 Stillwater. Minn...... 1 10, 4 ......

Sunbjry, Pa...... Surerior, Wis...... 167 11 5 2 ...... 47, 4 ..... Syracuse. N. Y...... SJr!9 44 10 1 2 13 7... 3. Tfa'-oma. Wash...... 117,446 ...... Taunton, Mass...... 36(10 13 ...... 4 Terre Haute, Ind...... 67,361 13 6. ....i.. 5 Toledo, C hio...... 202,1l0 53 55 1 20 6 Topeka, Kans...... 49,538 8 3. 15 5 ...... Trenton N. 3...... 113, 974 29 ...... 1 2...... Trinidad, Colo...... 14,413 5 ...... Troy, N ...... 78,04 26 6 ...... Tuscaloosa, Ala...... 10,821 .. 1 Uniontown Pa...... 21,f6.00...... I 1 ...... Vc1'ejo, Cali ...... 13,S03 ..... 1 2 V.-ncouver, Wash...... 13,605 ...... 6 Waco Tex 34,015 11 2 1 Waitiam lMass...... 31,011 7 2. 12 2... Warren, ..a...... 15,08.3 12 Washington, D. C. 369,2Q2 99 21. 4 25 1 2. Washiington, Pa...... 22,076 ...... 89 ...... Waterbulry, Conn...... 89,201 11 5. 2 IPulmonary tuberculosis only. November 12, 1920. 2748 DIPHTHERIA, MEASLES, SCARLET FEVER, AND TUBERCULOSIS- Contiuued. City Reports for Week. Ended Oct. 23, 1920-Continued.

Popula- Diphtheria. Measles. Scarlet Tuber-' tion as of Total fever. eulosis. July1,1917 deaths_____ City. (estimated from. by U. S. all .. . Census causes. 0 Bureaui). c

Watertown, Mass; ...... 15,188 6 3 ...... 2 ......

...... 1 Watertown N Y 30,404 ...... WaD u,iiW1s;. . 9,666 '6 1 .1...... I...... West 1ester, Pa.13,43 ...... 2...... I...... Weselds Mass ...... 18,769 . 4...... 3 1 West Hoboken N.J ...... 44,386 1 ...... 1...... WestNew Yoric, N.J. 19,613 5 .3 ......

...... West Orange N. J.... 13,964 1 5 ...... Wheel'g Wt. V . 43,657 17 5 1...... S...... White l-ls,N.Y. 23,331 5 ...... Wichita Kns 91773597 23 1 ...... 9 ...... WilkesiBarre Pa 78,334..... 8 6 8 . 3 5 ...... 9 .. 4 33 ...... Wilmlngton, i)el.95,369 9 1 ...... W imgton, N. C. 30,400812 Winchester1 Mass ...... 10, 3 ......

W Mona,Min ..118,583 ...... 3 ...... WinoSalem, N. C ...... 33,136 13 4 ...... Wot, ...... a.. . 13,105 6 ...... s...... 16,076 S .5. :...... 1..I Mass 166,106 39 1 1 2 12 7 3 WorcesterYo s, Y...... 103...... 066 13 8 2 2 1 2 York, a...... 52,770 ...... 6 ...... 1 ...... 3 ...... YoungstowPn, hio ...... 112,282 23 4 ...... 3 ...... I ...... Zanesvill, h'.io...... 31,320 3 _= .. . .

I'Population Apr. 15,1910. FOREIGN AND INSULAR.

CHINA. Cholera-Shanghai-September, 1920. An outbrealk of cholera, with a mortality of 33.3 per cent,- was reported, September 29, 1920, at Shanghai,. China. Two fatal -;6ases wero stated to have occurred in foreigners. The outbreak occitred in t. missionary college. CUBA. Communicable Diseases-Habana. Communicable diseases have been reported at Habana, as follows:

Sept. 1-10, 1920. Sem Sept. 1-10, 1920,. 1.karan- Disease. et Dise.se. eases.Nsew. Deaths. i90. eases.190New Deaths. Sept. 10,

Cerebrospinal men- Measles .12 1 28 ingitis ... ..11 Scarlet fever ...... 9 ...... 2 Diphtheria 11...... I Smallpox ...... 2 Leprosy ...... 11 Typhoid fever ...... 19 6 393 Malaria ...... 30 1 1 48

From the interior 30. 2 From abroad 2. 3 From the interior 35.

Sept. 11-20,1920. Remain- Sept. 11-20, 1920. Remain- ______-___ jing under _ ing under Disease. treatmenit Disease. treatment Noew Deaths. Sept. 20, New Deaths. Sept. 20, cases. 1920. cases. 192.

Cerehrospinni men- Malaria ...... 41 . 57 intis ...... 1 Measles ...... 9 3 20

...... Diphtheria ...... c...... arlet eer 1I Leprosy ------11 Typhoid fever 30 4 2101

I From the interior, 35. 2 From the interior, 35.

Sept. 21-30, 192D. Remain- Sept. 21-30,1920. Remain- ijgi under ingunder D isease. ~~~~~trea't-ment Disewse. rant Nw Sept.30, Dsae New Sept.30,s cases. Deathis. cases. Deaths. 1920.

2 Diphtheria ...... 3 1 111 Measles ...... --- 4...... 2 Leprosy ...... Scarlet fever 12...... | 53...... 1&81 Typhoid fever 12 1 276 I From the int(rior, 53. GALICLA 2 From the interior, 23. Cholera-Buczacz. Cliolera was reported present at Buezacz, Galicia, October 18, 1920. (2749) November 12, 1920. 2750 GREAT BRfTAIN. Anthrax-Bradford. The occurrence of a fatal case of anthrax at Bradford, England, was reported October 21, 1920. The case occurred in a wool handler. JAPAN. Cholera-Taiwan (Formosa). During the period August 22 to September 20, 1920,-548 cases of cholera with 378 fatalities were notified in the island -of Taiwan (Formosa), Japan. (Population, Census of 1918, 3,669,687). MEXICO. Plague-Infected Rodent-Vera Crux A plague-infected rodent was reported found at Vera Cruz, Mexico, during the week ended November 7, 1920: Yellow Fevet.(suspected)-Tampico. On November 4, 1920, a fatal suspected case of yellow fever was reported at Tampico, Mexico. The origin of the case w-as believed

to be Tuxpam, Mexico. I Yellow Fever-Tuxpam. During the week ended October 27, 1920, 27- cases of yellow fever were reported at Tuxpam, Mexico, with a total of 112 cases with 59 fatalities from August 26 to October 27, 1920. RUSSIA. Cholera-Grodno-Vilna. Cholera was- reported present, October 18, 1920, at Vilna and Grodno, Russia. CHOLERA, PLAGUE, SMALLPOX, TYPHUS FEVER, AND YELLOW FEVER. Reports Received During Week Ended Nov. 12, 1920.1 CHOLERA.

Place. Date. Cases. Deaths. Remarks.

China: Chungking...... Sept. 12-18 ...... Present. Dairen... Sept. 29....4 1 Nanking ..... Sept. 12-25 ...... 4 Shanghai ..... Sept.29 ...... 6. .... 2 foreigners, 4 Chinese. Chosen: Chemulpo...... Sept. 24-Oct. 7.... 4 6 Pusan ...... do .7 1 Mokpo .. Sept. 24-30...... 2 3 Seoul .... Sept. 24-Oct. 7.... 29 69 Calicia: Buczacz ...... Oct. 18...... Present. India: Bombay.... Aug. 22-Sept. 11... 14 9 Calcotta ....Sept. 12-18...... 17 17 Madras .... ept. 19-25 ...... 1...... Rangoon .... Sept. 12-18 .1...... 1 From medical officers of the Public Health Service, American consuls, and other sources. 2751 November 12,1920. CHOLERA, PLAGUE, SMALLPOX,- TYPHUS FEVER, AND YELLOW FEVER-Continued. Reports Received During Week Ended Nov. 12, 1920-Continued. CHOLERA-Continued.

Place. Date. Cases. Deaths. Remarks.

Japan: Taiwan (Formosa) ...... Aug. 22-Sept. 20: Cases, 548; PhIppIne rslands:.... de3ths, 37& . 19-25 ...... 2...... Provlnces-Manila .Sept.Sept...... Cagayan ...... Aur. 15-21 ...... 65 Cavite .. Sept. 5-11 ...... -1 1 Pangasinan ...... Aug. 1-7...... I 1 Rulssia: Grodno ...OOct. 18 ...... Present.

Vilna ...... do ...... Do. Siam: Bangkok .... Aug. 8-Sept 4..... 15 8

PLAGUE.

Ceylon: Colombo ...... Sept.12-18 ...... 3 Chile: Antofagasta . . Sept. 27-Oct.9.... 2 ...... China-

Amoy . . .. Sept. 12-18 ...... lidia ...... ; Atu. 15-Sept. I8,1920: Xes, Bombay..... Aug. 22-Sept. 11... 21 14 13, 464; deaths .9,570 Karachi ...... Sept. 19-5 ...... 9 9 Madras Presidency..Sept. 19-25...... 303 221 Rangoon...... Aug. &1... 7*6 57 Java: West Java . . . . . Sept. 3-9, 1920: Cases, 6: deaths, Siam:1Siam:Batavia ..Sept.3-9..... 6 6 6. Bangkok ...... Auig. 22-28 ...... 1

SMALLPOX.

Brazil: Pernambuco...... Aug. 16-Sept. 19... 98 Canada: Ontario- Hamilton...... Oct. 25-30. 1 ...... Noi? Bay ...... Oct. 17-23...... 2 ...... Ottawa...... Oct. 24-30. 42 ...... 1 SasKatchewan- Regina ...... Oct. 17-23...... 1 ...... Saskatoon...... do. 1 ...... Ceylon: 2 Colombo ...... Sept. 12-18...... 1 China: Amoy...... do ...... Foochow...... Sept. 19-25 ...... Present. Nanking,...... Sept. 12-25...... Do. Egy,gt: ltexcandria ...... S3ept. 24-30...... Cairo...... July 30 Aug. 5. _. .. 1 Gret Britain: Glasgow...... Oct. 3-16...... 2 India: 2 Bombay...... Aug. 22-Sept. 4 .... 4 ...... Calcutta...... Sept. 12-18...... I Madras...... Sept. 19-25...... 4 ...... 32 Rangoon...... Aug. 8-21...... 5 1 Italy: Palermo...... Sept. 17-30...... 95 Trieste. Sopt. 25-Oct. 2.... 16 Java: West Java...... Se?t. 3-9, 1920: Cases, 7; deaths, Batavia...... Sept. 3-9...... November 12, 1920. 2752 CHOLER4, PLAGUE, SMALLPOX, TYPHUS FEVER, AND YELLOW FEVER-Continued. Reports Received During Week Ended Nov. 12, 1920-Continued. SMALLPOX-Continued.

Place. Date. Cases. Deaths. Remarks.

. . Portuguese East Africa ...... Sopt. 12-18, 1920: Present in interior. Inhimbane ...... Sept. 1218 ...... 1 Louretaco Marques ...... 2 ...... o2 June 1-Aug. 31, 1920: Deaths, 1..- Russia:' Rigs . Sept. 7-23 ...... 2.....2 Spain: Baredl5na; ..: ...... Sept. 16-29 ...... 4 Conr.a ...... Oct. 15-21 ...... 1 1 Swedeni'- Stockholm ...... Sept.1-25 ..... 2 . Tunis: Tunis...... Oct.4-10 ...... 2

TYPH3US FEVER.

Belgium'sl Ghe4t# ...... Oct.3-9...... 3 China;.. Ant,Ung ...,,... Sept. 19-Oct.3b;..-20 4

le .dria...... Oct.1-7...... 1 1 Great Briftin:. Dublin ...... Oct. 116...... Portugal: Oporto ...S...... ept. 2G-Oct.2. 2 ...2 Russia: Latvia--. Rig& .Sept.7-23...... 25 ...... Tjirkrev:I Constantinople ...... Oct.&-9 ...... 3.|'.'.

YELLOW FEVER.

Mexico- Tampico ...... Nov. 4...... 1 1 Suspected. __am .ct. 21-27...... 27. Aug. 2 ct. 27, 1920: Cases 112;: 8 15 Vera z ;...... ,. Oct. 25-31 ...... deaths,59. Reports Received from June 26 to Nov. 5, 1920. CHOLERA.

Place. Date. Cases. Deaths. Remarks.

Brazil: Rio de Janeiro...... June 27-July 3...... 1 China: Amoy...... June 20-Aug. 14... 12 A ntung...... Aug. 9-15.... 1

Caniton ...... July I-Aug. 31... 5 4

Changsha ...... A ut. 22-S3pt. 18... 137 50 Aug. 15-21: Presenlt. Chungking...... May 16-24...... 1,319 Do ...... June 6-Sept. 11 ...... 5,322

Foochow ...... July 11-24 ...... Preseilt. Hainkow...... July 4-17...... 12 15 Harbin ...... X.....g4 ...... I. Year 1919: Cases 603. On East- Holngkong...... Aug. 8-14 .. 1 ern Chiniese . R. line. At other stations, same line, 190 cases.

.. Nan- Nalking ...... Aug. 30 ...... Several cases reported at ...... I king Reported Shanghai .... Aug. 2-29...... 6 Uiniversity. prevalent among Chinese. 13 000; Chosen (Korea)...... Sept. 8, 192Q: Cases, Chemulpo...... Aug. 1-Sept. 23... 15 deaths, 5,000 (estimated). Aug. Chinnampo...... Aug. 1-26 ..... 34 23 1-Sept. 23, 1929: Cases, 22,435; Fusan...... Aug. 1-Sept. 23... 677 492 deat,hs, 11,003. Gensan...... Aug. 27-Sept. 2... 1 Mokpo...... Aug. 1-Sept. 9.... 26 la Seoul...... Aug. 1-Sept. 23... 1,003 7112 2753 November 12, 1920. CHOLERA, PLAGUE, SMALLPOX, TYPHUS FEVER, AND YELLOW FEVER-Continued. Reports Received from June 26 to Nov. 5, 1920-Continued. CHOLERA-Continued.

Place. Date. Cases. Deaths. Remarks.

Greece: Patras...... July 26-Aug. 1...... Present in surrounding country. Zante...... Aug. 2-8...... Present. India ...... i.. Apr. 11-May 22, 1920: Deaths, Bombay...... May 2-June 26.... 85 7549 May 30-June 26, 1920: Do...... June 27-Aug. 21... 89 57 lieaths, 3,710. June 27-July 10, Calcutta .... May 2-June 24.... 439 42 1920: Deaths, 1,711. Do...... July 18-Sept 11 ... 158 151 Madras...... May 2-June 26. 20 13 Do...... July 11-Sept. 18... 10 1 Rangoon...... June 27-July 4... 21 16 July 1-31, 1920; Cases, 18; deaths 16. Indo-China...... Jan. 1-31 1920l: Cases 40: deaths, 24. Feb. 1-29, 1926: Cases 25; .Saigon ...... Apr. 26-June 13... 130 . 94 deaths, 15. Mar. 1-31, 920: Do...... July 20--Sept. 5.... 9 5 Cases, 52; daths, 30. Japan: Kobe...... June 14-27...... 36 24 Kobe, Jtue 6-13 34 cases. IMoji Do...... June 28-Sept. 23... 408 223 June 6-12, 16 cases. Kocpl, Nagasaki.. Jume 21-27...... 7 ...... 62. June 6-12i 1 case. - Hiros Do...... June 28-July 18... 34 June 6-12, 6 case. Osaka...... do...... 6...... i. Taiwan Island...... May 22-June 20 ... 60 Do...... July 11-Aug. 20... 645 -i 62 Java: West Java- Batavia...... Apr. 30-June 3 .... 6 2 4-17; Present. Do...... June 25-Aug. 12... 3 ..... June Philippine Islands: Manila...... May 9-June 26f... 5 Do...... June 27-July 10. . 3 ......

Provinces...... 1 ...... May 9-June 26, 1920: Cases, 16; Albay...... May 9-15...... 1 deaths, 12. June 27-July 17, Batangas...... June 27-July 3.... 1 1920: Cases, 63. deaths, 31. Bohol...... do . 1 July 25-31: Cases, 57; deaths, 48. CagaFan...... Mav 9-June 26.... 19 June 27-July 10 ... 3513 9 Iloilo... June 27-July 17 ... 3 I...... Isabela...... July 11-31...... 13 14* Laguna...... July 4-10...... 8 ...... Misamis...... Juty 11-17...... 4 2 Nueva V,scaya...... July 25-31...... 49 42 Pangasinan...... July 4-17...... 6 4 roaana: Warsaw ...... Oct. 28 1 Case occurred in employee on river boat plying between Warsaw and Danvig.

Russia ..... It.F.. Reorted prevalent in southem Russia Jun 4, 1920. Sebastopol (district)...... June 20. I...... Reportedincrasing. Simferopol ...... I...... Jan.-June, 1920: Cases 1,262- deaths, 584. South Russia Government of Tauride. Vitna...... Sept. 28...... 40 ...... Province of Lithuania. Siam: Bangkok...... Apr. 25-Junc 26... 542 343 Do. : June 26-Aug. 7.... 46 18 Straits Settlements: Singapore...... Juily 18-Sept. 14... 24 23 Sumatra: Medan...... Aug. 20-Sept. 3.... 1 On local steamship. From Sin. gapore. Turkey: Amassia...... Dec. 24...... 1 ...... Asiatic Turkey. Kaiscri ...... Dec. 2...... Do. Karassi...... Jan. 3 ...... Do. Mamuret-ul-Aziz ...... Dec 31 ...... 1 Do. Panderma...... D)ec.- Jan...... 1 6 Rodosto...... Dec. 29...... 1 EuroPean Tuirkey. Smyrna ...... Dec. 22...... 3 Asiatic Turley. On vessel: S. S. Keketticut...... Aug.2.2...... 1 U. S. S.: at Shanighai. Steamship...... Aiug. 20-Sept. 3.... 1 At Medan, Island of Sumatra. From Singapore. 15712Q-,90.4 November 12, 1920. 2754 CHOLERA, PLAd'UE,. SMALLPOX, TYPHUS FEVER, A-ND YELLOW FEVER-Continued. Reports Received from June 26 to Nov. 5, 1920-Continued. PLAGUE.

Place. Date. Cases. Deaths. Remarks.

Algeria: Algiers Sept. 1-30,1920: Cases, 3; deaths, Azores: St. Michaels ...... I Oct. 4-20 '24&5 12 Oct. 4 1920: 5 suspect eases Lso. latea vicinity of Ponta Del- gada. Oct. 1-31, 1920: Cases, 76; deaths, 27. Ponta Delgada...... Oct. 1-26...... 2 Brasil: I3abla...... Apr. 25-May 22 ... 10 10 Do...... June 27-Oct. 28... 10 5 Pernambuco...... Mav 3-9...... 1 1 Do...... June2-Aug. 15...1 32 16, Porto Alegre. June 27-Aug. 21... 2 British Fast Africa...... Apr. 1-30, 1920: Cases, 22; deaths, Kisumu_ ...... jcApr. 25-June 26... 12 9. Do... July 11-SePt. 4.. 10 5 Present. Mombasa...b...... Apr. 25-June 28.... 104 39 ...Do...... June27-Aug. 28. .. 113 72 Nairobi ...... ;.. Apr. 25-Jux4e 10.... 14 8 Ceylon; olombo...... May 25-June 12.... 7 2 .Dos Jine27-Sept. 4.... 18 1 Chile...... Mar. I-May 81, 1920: Vases 15; . deaths, 2. Plague. reported In Denartments of Tacna and Tarata. Antofagasta...... May 17-June 20... 5 ...... I Mar. 1-May 31, 1920: Cases, 7; Do...... Julv 5-11...... 1 deatls, 1. Iquique...... Mar. 1-May 31..... 8 China: Amov. June 2D-Sept 11. .. 7 Hongkong...... Apr. 4-June28..... 70 Do...... June 27-Aug. 21. .. 26 23 Ecuador: Guayaquil...... Aug. 16-Sept. 30... I Egypt...... --..-. -- ...... ran. 1-Sept. 30, 192): Cases, 420, Cities- deaths,W45. Alexandria...... June 18-Aug. 12... 10 7 Port Said...... Aug. 2-Sept. 28.... 3 Suez...... May 13-June8..... 12 .6] 3 cases pneumonic. Do...... July 3-Aug. 4..... 4 31 Provinces Assiout . May 1-June5..... 7 Do...... July 2-14...... 6 Beni-onef. July 7-10...... 2 Fayoum ...... June 5...... Garbieh...... do ...... Do...... July 1-Sept. 28.... 19 ii. Keneh...... May 18...... 1 ...... Mariut...... Ma 18-June 8.... 19 22 Do...... July 3-9...... I 2 Minieh...... May 15...... 1 Septicemic. Do...... July 13...... 1 ...... ' Fiume ...... Sept.21...... Great Britain: Liverpool...... June 20-26...... Greece: Athens...... Aug. 10-Oct. 14... 21 Chios .;; Oct. 14...... Dante.Da t...... July 22...... 2 ...... I Kavallia . July 5-Aug. 21.... 3 ...... Nauiplia...... Aug. 21...... 2 ...... -. Approximately 20 cases Sept. 9. PirTus...... June 29-Sept. 20... 12 Saloniki...... Sept. 25-Oct. 8.... 3 ...... Zante...... India...... 1 Apr. 18-June 26, 1920: Cass, Bombay...... Apr. 18-June 26... 170 12,476; deaths, 9,961. June 27- Do...... June 27-Aug. 21 ... 34 31135 Sept. 4, 1920: Cases, 13,922; Calcutta...... May 2-June 12.... 26 19 deaths, 11,270. Karachi...... May 9-Sept. 11.... 67 60 Madras Presidenty. May Sept 18.... 6,198 4,509 Ranfoon...... Apr. 25Juno 26... 120 Dvo...... June 27-Aug. 7.... 157 ...... 13.. 2755 November 12, 1920. CHOLERA, PLAGUE, SMALLPOX, TYPHUS FEVER, AND YELLOW FEVER--Continued. Reports Received from June 26 to Nov. 5, 1920-Continued. It PLAGUE-Continued.

Place. Date. Cases. Dcaths. Remarks.

Indo-China ...... Jan. 1-31, 1920: Cases, 42; deaths, Saigon...... May 10-June 13... 9 '2 40. Feb. 1-29 1920: Cases 41- Do ..... July 26-Aug. 13... 5 4 deaths 36. ICar. 1-31, i92o Cases, .9; deaths, 70. Italy: Catanla...... June 22-July 3.... 3 2 Java: East Java...... Apr. 23-May 5, 1920: Cases, 7; West Java- deaths 7. Apr. 15-June 16, Batavia...... July 22-Aug. 8.... 9 9 1920: (ases 8; deaths S Aug. 5-25, 1920: Cases, 4; leths, 4. Surabaya Residency. Mesopotamia: Bagdad...... June 1-30...... 6 3 Mexico: Tampico...... July 26-Sept. 27... 4 3 Vera Cruz ...... June 14-20. 11 I May 29-July 14, 192D; Cases 49 Do...... July 18-24...... 2 2 deaths, 29. Corrected siate ment: From outbreak in MaY to July 20, 1920-cases, 5; desths 36 rent ...... I...... Mar. 1-3i, l92O: Cases, 46; deaths, Callao...... Mar. 1-31. 3 29. Apr. 1-30 1920: Cases; 36; Do ...... Apr. 1-30...... 9 4 deaths, 13. I coastal depart- Lima 'city).. Mar. 1-31. 5 3 inents. Do ...... Apr. 1-30. 4 4 Lima (country) ...... Mar. 1-31...... 1 1 Do...... Apr. 1-30...... 1 ...... 2. Mollendo...... Mar. 1-31. 13 Paita ...... do ..-- 5 2 Do...... Apr. 1-30. 2 ...... Salaverry . Mar. 1-31. 4 Do...... Apr. 1-30..... 1 11 San Pedro...... do...... 6 13 TruLl)o-Salaverry...... May 31-June 29. . 3 2 Do ...... Aug. 30-Sept. 5... I 11 Russia: Batum...... Sept. 28...... PrcTalcnt. Siam: ...... ' Bangkok...... Apr. 26-June 5.... 8 Do...... June 28-July 17... 5 23 Straits Settlements: Singapore...... Apr. 25-June 19... 14 1363 lJo ...... July 11-Aug. 7.... 3 Syria: Beirut...... June 30...... Present. Turkey: Constantinople...... July 25-Aug. 21... 7 6 Uruguay: Montevideo...... June 1-30...... 1 1

SMALLPOX.

Algeria: Departmelnts- Algiers ...... May 11-Aug. 31... 51 ...... City of Algiers, Apr. 1-30, 1920: Constantine ...... June 1-Aug. 31.... 18 ...... One case. July 1-Aug.. 31, Cranl...... May 11-Aug. 31... 168 ...... 19: Cases,4: deaths, 2. Austria ...... May 30-June 26, 1920: Cases, 27. Viennia...... May 30-June 26...... June27-July 10, 1920: Cases, 22. Azores: Pojita Delgada...... Juily 17-Aug. 20... 7 ...... St. Michels...... Aug. 21-27...... 1 ...... From Madeira. tBolivar: La Paz...... Mfay 2-June30.... 10 8 Do ...... July 1-Aug. 31.. 11 5 Brazil: B3ahia...... Apr. 25-June 26... 5 5 Do...... June 27-Aug. 21... 20 2 Pernambuco...... Mar. 29-June27. .. 114 3 Do...... June 30-Aug. 15... 112 2 Rio de Janeiro...... Apr. Il-June 26... 431 6 Do...... June 27-Aug. 21... 45 9 November 12, 1920. 2756 CHOLERA, PLAGUEw SMALLPOX, TYPHUS FEVER, AND YELLOW FEVER-Continued. Reports Received from June 26 to Nov. 5, 1920-Continued. SMALLPOX-Continued.

Place. Date. Cases. Deaths. Remarks.

Brazil-Continued. anto...... Mar. 24-28...... 1 ...... Sao Paulo...... Juno 21-27...... I Do...... June 27-Aug. 8.... I...... 1 British East Africa...... I...... Mar. 1-31, 1920: Cases, 107. Apr. Mombasa...... May 2-22...... 2 ...... - 1-0,1920: C.ases, 69. Reported Do...... July 11-17... 3 I by native inspector Nairobi...... May 23-June 26... 11 ...... i. Do...... Aug. 1-21...... S Bulgaria: ...... Sofia...... July 11-17...... Canada: Alberta- ...... Calgary...... Jume 1 Do...... July 4-Oct.3-9...... 9...... 6 ...... British Columbia- ...... Vancouver...... May 16-Aug. 28... 4 Manitoba- ...... Winnipeg...... May 29-Juno 5. 3 Do...... Aug. 8-21...... 2 ...... New Brunswick- ...... Bonaventuraand Gaspe Aug. 1-31...... 1 Ceunties. .*...... Carleton County..., Sept. 19-25...... Cloucester County..... May 31-June 26... 51 ...... Do ...... Sept. 19-Oct. 9.... 3 Queens County...... July 4-Aug. 21.... 7 ...... Restigouche County... - ...... 1.-.3.1...... Sept. 26-Oct. 2, 1920: Cases, 1. Camnpbellton...... July 1-31...... 7 Nova Scotia- Ilalifax...... do...... 22 1...... Sydney...... May 31-June26...... Ontario- Cornwall...... June 25-30...... 2 Fort William and Port July 11-Oct. 2..... 4 :...... Arthur. Hamilton ...... June 13-Oct. 16.... 8 Kingston...... May 31-June 19. . . 4 North Bay...... June 23-2..... 1 Do...... July 11-Oct. 9... 6 Ottawa...... June 6-26...... 32 Do...... June 27-Oct. 9.... 64 Peterborough...... Apr. 18-July 31.... 33 Prescott...... July 11-17...... & ...... Do...... Aug. 1-14...... Present at Cardinal and Brock- Toronto...... June6-19. -...... 13 ...... ville. Do ...... June 26-Sept. 25... 26 .------Windsor... Aug. 22-Sept. 11.. 5 ...... Prince Edward Island- Charlotte Town...... Aug. 12-Oct. 13... 2...... Quebec- Montreal...... June 13-19...... - Do...... July 4-Aug. 7...... Quebec...... June 27-Oct. 2...... Saskatchewan- .. Moose Jaw...... June 26-30...... Do...... July 25-Sept. 25... 6...... Regina...... Juno 2-30...... 1 ...... Do...... Oct. 3-9...... Saskatoon...... Sept. 5-Oct. 16.... Ceylon: Colombo...... May 9-June 5..... 2 ...... Do...... Aug. 29-Sept. 4.... 8 ...... Chile: Antofagasta...... _ May 17-23...... 1 casein Interior. China: 1...... Amoy...... May 2-Sept. 11.... 42...... Antung...... May 9-June 13.... 3. Do...... June 21-27..... 1 ...... Chungking...... May 2-June 9...... Present Do...... July 11-Sept 11...... Do. Foochow...... May 9-29...... Do. Do. July 2-Sept. 18... Do. Hankow...... June 20-26...... 2757 November 12, 1920. CHOLERA, PLAGUE, SMALLPOX, TYPHUS FEVER, AND YELLOW FEVER-Continued. Reports Received from June 26 to Nov. 5, 1920-Continued. SMALLPOX-Continued.

Place. Date. Cases. Deaths. Remarks

China-Continued. Harbin...... Year, 1919:Cases,79. OnEastern Apr. 4-June 26.... 19 is Chinese R. R. line. At other Honlrong..... June 27-July 17... 2 2 stations, 109 cases. Mukden. July 19-Aug. 21...... Present. Nanking. May 9-June 5...... Do. Do. July 4-Sept. 11...... Do. Tientsin. ay 25-31...... 2...... Do. June 16-29...... 2 ...... Tsinanfu. May 9-15...... 1 ...... Chosen (Korea): Chemulpo. mar. 1-June 30.... 69 40 Do...... July 1-31...... 18 8 Fusali. Mar. 1-June 30.... 24 6 Do. July 1-31...... 1 1 Seoul . Mar. 1-June 30.... 358 86 Do...... July 1-31...... 15 6 Colombia: Barrasnquilla...... May 13-July 3...... I...... Epidemic. Santa Marta...... May 31-Oct. 16...... Present. Cuba: Antilla...... Aug. 24-Sept. 13... 2 ...... Habana...... July 4...... 1 ...... From steamship Frank Hennis from Jamaica. Arrived Santi- sgt June 3C, 1920. Matanzas...... Aug. 15-21...... I 1 -1 In vicinity, at Aguacate, Aug. 1-7, 1920: Cases, 12. Cyprus ...... August, 1919: Cases, 242; deaths, . 54. Czechoslovakia: Moravia...... Feb. 1-2...... 68 Danzig...... June 20-July 17... 9 2 Egypt: Alexandria.. MIay 14-June 29.... 53 19 Do...... June 25-Sept. 23... 12 3 Cairo...... Apr. 2-June 24.... 62 23 Do...... July 2-8...... 1 ...... rort Said...... Apr. 2-June 24.... 22 Do...... July 2-15...... 2 1 France: Brest...... May 1.5-31...... 1 Cette...... June 24-30...... Niee...... June 1-30...... 1 Paris...... May 1-10...... Germany...... Feb. 22-June 12, 1920: Cases, 720X - July 11-24, 1920: Cases, 26; deaths, 6. Additional cases, June 137July 10, 1920, 24; deaths, 2. Great Britain: Edinburgh...... Aug. 29-Sept. 4.... 7 I1 Glasgow...... May 25-June 26.... 136 22 Vo...... July 4-Oct. 2...... 169 46 Liverpool...... July 18-Sept. 11... 2 ...... London ...... Jun 13-July 19... 14 ...... Manchester...... Aug. 22-28...... 5 ...... Greece: Saloniki...... May 31-June 27.... 4 I Do...... July 25-Aug. 15 ... 1 Haiti: Port au Prince...... Scpt. 22...... 5 ...... India...... , ...... I...... Apr. 11-May 22, 1920. Deaths, 7 743 May 30-June 26, 1920:. l5eaths, 3, 864. Bombay. Apr. 26-Junie 26... 103 45 May 9-15, 1920: Cases, 26; deaths, Do...... Jtiie 27-Aug 14. 45 9 11. Calcutta...... May 2-Jutne 12 .... 101 93 Do...... July 18-Aug. 21... 8 Karachi...... May 9-Juile 26..... 15 12 Do...... June 27-July ID.... 7 4 Madras...... May 9-June 26.... 27 15 Do...... June 27-Oct. 4..... 38 12 Rangoon...... Apr. 25-June 26... 35 14 July 1-31, 1920: Cases, 22; deaths, 4. November 12, 1920. 27!8 CHOLERAA, PLAGUEw SMALLPOX, TYPHUS FEVER, AND YELLOW 1FEVER-Continued. Reports. Received from Jon 36 to Nov. 5, 1920-Continued. SmALLPOX-Continued.

Place. Date. Cases. Deaths. Remarks.

Indo-China...... Jan. 1-31 1920- Caws 410; deaths, 101. Feb. 192b1129 Cses, Saigon ...... May 10-June 13 121 1 deaths, 19. kar. 131, 1920: iD o ...... Au:g.3-sept. 5...... Cass 782; deaths, 4. Italy: Catania...... I July 12-Oct. 3. . 91 ....*..... City and Province, Sept. 13-26 69 cases in district. Genoa...... May 17-23...... 12 ...... In Province Do...... June 14-27...... 20 ...... Do...... June 28-July 4.... a ...... Messina...... May 10-June 27. .. 7 Province, May 10-June27: Cases 168i deaths, 27. Do...... June 28-Sept. 26... 13 3 Province: Cases, 35; deaths, 3. Milan...... Mar. 1-May 31.... 3 5 Naples ..... May 23-June 20. .. 7 3.

Pa'ermo ...... May 11-Sept. 16... 166 29 Turin...... June 28-July 4. ... 1 ...... Jamaica: Kingso...... July 22...... Present. Japan: Kobe...... May 9June 27.... 10 5 Do...... June 28-July 18... 7 2 Taiwan Island ...... May 1-June 20.... 40 11 Do...... - Jane 21-July 20.".. 14 8 Tokyo...... 4pr. 21-May 10... 5 4 lava: ...... Apr. West Java...... 1.. 16-June 24 1920: Cases, 56; Batavia...... A r. 16-1(ti.e' ii..'.-, 94 deaths, 10. June 2.5-Sept. 2, Do...... JZ 9-Sept. 2..... 1 1920: Cases, 68; deaths, 15...... Feb. I-June23, 1920: Caes, Jugo-Slavia...... 2,519; deaths, 561. Madeira: Funchal...... June 20-26 ...... 2 1 Do...... July 18-24 ...... 1...... Sept. 12-18, case...... Malta...... tay 1-June 30.... Manchturia: Mulkden...... May 2-8...... Mesonotamia: ..._...... agdad ...... July 1-31...... Mexico:P 1 Cindad Juarez...... Aug. 2-8...... Guadalajara...... May 1-31...... 1 Do...... July 1-31...... 3 Laredo ...... July 30. 2 Ma-atlan...... May 19-25...... 1 Salina Cruz...... June 1-0...... 3 Do ...... Aug. 1-31...... 1.1 San Luis Potosi...... May 31-June 6...... I 11 Do...... June 28-Oct 10...... I 1 Tampico...... July 1-31...... Newfoundland: ...... I Broad Cove...... Sept. 4-10...... 1 ...... Ladle Cove...... Sept. 11-17...... 6 ...... St. John's...... June S-11...... 3 ...... Reportod at 2 other localities. Shoal Harbor...... July 10-16...... 7 ...... July 3-10: Present at 4 localties. New Zealand: Dunedin...... Aug. 10-23 ...... 7 ....-31, 1920: ...... Cases, 1,895; Poland...... 3an...... Jan. 1. Minsk District...... Jn1-31...... 1,052 228 deaths, 301. Porto Rico: Caguas...... Aug. 9-15...... 1 Portugal: Lisbon...... May 16-June 28... 8 Do...... June 27-Oct. 9.... 20 Russia: Riga ...... Aug. 1-7...... 1 ...... Mgay, 1920: Cases, 3. June, 1920: Vladivostok...... Jpn. 1-Jume 30.... 252 ii8 Cases. 7. Do...... Jlsly 1-31...... 2 ...... Spain: liareelona...... 1fay 19-June 12...... 4 Do...... Jpye 18-Sept 8...... 16 Corunna...... Jtuly 16-29...... 3. Mfalaga...... Aug. 1-31,1920. Dcaths, Orense Province...... Sept. 6...... Present. Valencla...... May 23-June 20 .. Do...... July 4-Oct. 2. 11 3 Vigo...... May 31-June 26...... 4 Do. July 18-Oct. 2...... 10 2759 Novembe 12, 1920. CHOLERA, PLAGUE, SMALLPOX, TYPHUS FEVER, AND YELLOW FIER-ontinued. Reports Received from June 20 to Nov. 5, 1920-Continiued. . SMALLPOX2-Continned.

Place. Date. Cases. Deaths. Remarks.

Switzerland: 0eneva ...... May 9-15...... 7 Syria: Aleppo ...... Aug. 29-Sept. 4 ...... In city and in Armenian orphan- Tunis: age. Tpnis ...... May 25-June27 6 5 Do ...... June 28-Sept. 19 38 10 Turkey: Constantinople.May 111-June 19... 7. Do . June 20-Aug. 28... 12 . Union of South Africa: Johannesburg ...... May 1-31 .23 . Do ...... July 1-31.15 . On vessel: S.S. Henry R. Mallory.... Oct. 2 .1 .. . At Habana from Spanish ports. Vessel left Vigo, Spain, Sept. 19.

TYPHUS FEVER.

Algeria:. Departments- Algiers...... May 11LAug. 31... 44]...... Constantine...... May21-Aug.31 20 ......

Oran...... May 11-Aug. 31 _. 352 ...... Austria ...... , ...... Feb. 15-June 26, 1920: Cases, 67. Vienna...... Feb. I15 JIm . . 6 ...... Belgium: ]26. Ghent...... Sept. 11-25...... 6 1 Bolivia: La Paz...... Mav 2-Juno 30. 17 Do...... July 1-31. Brazil: 12 Ceara...... Apr. 25-June 12... 4 Do...... July 11-24. 2 Bulgaria: Sofia...... June 20-25 ...... 21 Chile ...... Mar. 1-June 30, 1920: Cases, 1,338, deaths, 244. Antofaeasta...... Jutly 5-11...... Present. Caleta Coloso ...... May 10-16...... Concepcion ...... Mar. -June 28....1 31 39 Do...... June 29-Sept. 20...1 ...... , 13 Coouiimbo...... Aug. 8-15...---.--. Santiago...... Mar. I-Jmne 30... 470 ...... 99. Sept. 10: Cases, 186. Valparaiso...... lMay 2-Sept. 24...... 99 China: Antung...... July 12-Sept. 13 1...... Report weekended July 31, 1920 5....I not received. Fastem Chinese Railway... Aug. 9-Sept. 28...... At stations on line. Harbin...... I...... I...... I...... On 1 astern Chinmse Railroad Line. Year 1919: Cases, 301. At other stations on line, 789 Chosen (Korea): Chemulpo...... Jlne 1-30...... 3 Swill...... Mar. 1-Apr. 30.... 4 Czechoslovakia...... Feb. 1-28, 1920: Cases, 88; deaths, 7. Leipik...... Feb. 22-28...... Quarantine station. Danzig...... June 20-26...... 1. Feb. 27-Mar. 27, 1920: Cases, 16. Do...... July 25-31...... Egypt: Alexandria...... May 7-June 24..... 338 so Do...... June 25-Sept. 9.... 141 62 Cairo...... Apr. 2-June 24. 867 370 Do...... Ary 9-22e...... 41 Port Said...... Apr. 9-Jume 24....! 112 5B November 12, 1920. 2760 CHOLERA, PLAGUE, SMALLPOX, TYPHUS FEVER, AND YELLOW FEVER-Continuetd. Reports Received from June 26 to Nov. 5, 1920-Continued. TYPHUS FEVER-Continued.

Place. Date. Cases. Deaths. Remarks.

Germany...... Feb. 22-Mar. 27, 1920: Cases, 23. Among troops, 4: among persons from Poland, 8. Mar. 28- June 26, 1920: Cases 96. July 11-24, 1920: Cases, 2. Add, I tional cases, June 1-uly 10, 16. Great Britain: Dublin...... May 23-June 19.... 3 1 Do...... Oct. 16-22...... 17 ...... Dundee...... July 4-10...... 1 ...... Glasgow...... May 30-June 5..... Aug. 1-7...... Greece:Queenstown...... , Athens...... June 27-July 21...... 5. Drama... July 12-18...... Patras...... June 29-July 4.... Pirxus...... June 29-July 5...... 1 Sloniki...... Apr. 12-27...... 42 Do...... June 28--ept. 12... 128 54 Guatemala: Guatemala City...... Aug. 9-15...... 1 ...... Jan. 19-May 30, 1920: Cases, 54. BUdZaPeSt...... Jan. 10-May 23...... ItaT Catania...... July 10-17...... 3 ......

.... . May 16-22...... 5 ...... ETiesteDo...... June 13-Sept. 21... 159 Japan: Robe...... Aug. 17-23 .....: 7 Nagasaki .... . May 25-June 27. .. 2 1 Do...... Sept. 13-19. 1 ...... Java: East Java- 15 Surabaya...... June 10-16. 1 ...... West Java- Batavia...... May 28-Jme 30. .. 5I Jugo-Slavia...... I...... Feb. 1-June 23, 1920: Cases, 691; deaths, 92. Mesopotamia: Bagdad...... Aug. 1-31...... Mexico: Chihuahua...... May 31-June 6.... 1 Nogales ...... Aug. 9-14...... San Luis Potosi...... June 8-July 8.. _ Present. Do...... Jtily 2-Aug. 15.... £ept. 19: Present. Poland...... Jan. 1-Mar. 31, 1920: Cases, 87,910; deaths 19,733: Warsaw...... Jan. 1-F'eb. 29, 1920: Cases, 911; deaths, 117. Serbia...... Mar. 14-Apr. 10, 1920: Cases, 181; deaths, 23. Portugal: Oporto...... Apr. 4-June 24.... 15 6 Do...... Aug. 1-14...... 3 ...... Russia: Riga...... June 25-Sept. 7.... 43 ......

...... 1920: Simferopol ...... !...... Jan.-June, Cases, 3,955; Vilna...... Shpt. 28...... 35 ...... deaths, 500. Vladivostok...... Mlay 1-21... 22 2 Jan. 1-Apr. 30, 1920: Cascs, 1,264; Do...... July 1-Aug. 31.... 36 4 deaths, 144. Spain: Barcelona...... July 9-15...... Madrid...... June 1-30. Switzerland: ...... 1 I Geneva...... June 28-July 4.... 1 ...... Tunis: Tunis ...... May 24-June 27. .. 36 Do...... July 6-Aug. 31.... 18 Turkey: Constantinople...... May 16-June 12... 27 ...... 1 Do...... June 19-Sept. 18... 18 ...... Venezuela: Maracaibo...... July 21-27...... I 2761 Nlovember 12, 1920. CHOLERA, PLAGUE, SMALLPOX, TYPHUS FEVER, AND YELLOW FEVER-Continued. Reports Received from June 26 to Nov. 5, 1920-Continued.I YELLOW FEVER.

Place. Date. Cases. Deaths. Remarks.

Brazil: Bahia...... May 23-June 19 ... I Colombia: Bu3naventura ...... June 3 ...... 1 Guatemala...... Oct. 25, 1920: Present. Los Amates...... u ...... iSept. 1 ...... 1( .3 Aug. 17: IPreseiit at several local. Aug. ities Aug. 5-23, 1920: Cases, 8; deaths, 6. Quirigta ...At. 9-15 ...... I'resenit. Virginia ...... Sept. 10 ...... Station on railway from Puerto Bavrios to (uatemala City, 45 miles from Puerto Barrios. Mexico: Culia'an ...... Oct. 16...... Present, Empalme...... Oct. 12 ...... Gualimas...... t ...... Previously reported, 2 dcaths; Mazatlan ...... Oct. 13..... 1I laterinfrmation shows Ideath. Progreso ...... -.-.*..* July -30. 1 Do...... - . .- Aug. 4-18. .21 July 30-Aug. 18, 1920: as , 5; deaths, 3. Puerto Mexico ...... I Attg. 24-27. Case arrived Augr. 23 on,. s. -1 Melhor Ocampo, from Pro- greso. Previuusly reported P. San Illas...... Sept. 13 ...... H. R., Sept. 10, 1920. TamNiLo::...... Srpt. 17... Stated to have arrived from lo...... Sept. 21-27 .... Tuxpam. Tuxpam ...... Sept. 1...... 2 Auo. 26-Sept. 1, 1920; Cases, 5; Vera Crnz...... Jutic 22...... 2 deaths, 5. Do...... July 19-Oct.17.... 46 Yticatan, State- 1 Campc-he...... Oct. 13...... 14 ...... In sailor from s. s. Yumuri. The 11 vessel ieft Vera Crus Oct. 1 for ...... 1 Campe-he and New Orleans. Hocoba ...... Sept. S...... In interior. Hunu ma...... Sept. s-Oct. 11.. 2 Do. Sotuta ...... Sept. 8...... 1. D)o. reru...... Mfar. 1-31, 1920: Cases, 228; Apr...... 1-20, 1920: Cases, 64. Callao ..... Apr. 1-30 At qtLaranitinn station. From Cata-aos ...... ar. 1-31. 8112 ...... s. s. Iluallaga. I)o .Apr. 1-30...... 2 ...... La Hluaa...... Mar. 1-31 . 91 ...... r Do. 1-30. 5 ...... Apr. - 14 ...... Morropon ...... do 3714 MunulHla ..... Mar. 1-31. 12 ...... Paita . .. do. 81 Do Apr. 1-30. 14 Piura Ma.,ar. 1-31 1 Do . Apr. 1-30 4 Salitral ....Mar. 131...... -a- 2 ......

Sullana ...... do .... 9

Do ...... Apr. 1-30. 1 SalIvador ...... Sept. 12-18, 192): lease; Au°.22. Armenia ...... June 20-26 ...... 1 Oct.11; 1920: Casas 3; deaths, 1. San Salvador ...... Aug. 1-21. 6 2 Fatal cases were in i:uropcans. Sonsonate...... May 22-June 24. 49 17 On vessels: S. S. Haraldshatig...... Sept. 28. 1 At Pensacola, Fla. From Puerto Barrios, Tampico, and Vera 1.. Cruz. S. S. Soestdijk ...... Sept. 11. At Quarantine, La. S.5. Yumuri...... Oct. 13...... At Campeche. Vessel left Vera Cruz Oct. 1, 1920. I -